Introduction: The coronavirus disease 2019 (COVID-19) pandemic has been shown to increase levels of psychological distress among healthcare workers. Little is known, however, about specific positive and negative individual and organizational factors that affect the mental health of emergency physicians (EP) during COVID-19. Our objective was to assess these factors in a broad geographic sample of EPs in the United States. Methods: We conducted an electronic, prospective, cross-sectional national survey of EPs from October 6–December 29, 2020. Measures assessed negative mental health outcomes (depression, anxiety, post-traumatic stress, and insomnia), positive work-related outcomes, and strategies used to cope with COVID-19. After preliminary analyses and internal reliability testing, we performed four separate three-stage hierarchical multiple regression analyses to examine individual and organizational predictive factors for psychological distress. Results: Response rate was 50%, with 517 EPs completing the survey from 11 different sites. Overall, 85% of respondents reported negative psychological effects due to COVID-19. Participants reported feeling more stressed (31%), lonelier (26%), more anxious (25%), more irritable (24%) and sadder (17.5%). Prevalence of mental health conditions was 17% for depression, 13% for anxiety, 7.5% for post-traumatic stress disorder (PTSD), and 18% for insomnia. Regular exercise decreased from 69% to 56%, while daily alcohol use increased from 8% to 15%. Coping strategies of behavioral disengagement, self-blame, and venting were significant predictors of psychological distress, while humor and positive reframing were negatively associated with psychological distress. Conclusion: Emergency physicians have experienced high levels of psychological distress during the COVID-19 pandemic. Those using avoidant coping strategies were most likely to experience depression, anxiety, insomnia, and PTSD, while humor and positive reframing were effective coping strategies.

IntroductionThe emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.MethodsThe task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors.ResultsEight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area.ConclusionThe evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

IntroductionIn the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs.MethodsThe task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II).ResultsIn Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED.ConclusionEmergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs.

Introduction Emergency departments (ED) manage a wide variety of critical medical presentations. Traumatic, neurologic, and cardiac crises are among the most prevalent types of emergencies treated in an ED setting. The high volume of presentations has led to collaborative partnerships in research and process development between experts in emergency medicine (EM) and other disciplines. While psychosis is a medical emergency frequently treated in the ED, there remains a paucity of evidence-based literature highlighting best practices for management of psychotic presentations in the ED. In the absence of collaborative research, development of best practice guidelines cannot begin. A working group convened to develop a set of high-priority research questions to address the knowledge gaps in the care of psychotic patients in the ED. This article is the product of a subgroup considering “Special Populations: Psychotic Spectrum Disorders,” from the 2016 Coalition on Psychiatric Emergencies first Research Consensus Conference on Acute Mental Illness. Methods Participants were identified with expertise in psychosis from EM, emergency psychiatry, emergency psychology, clinical research, governmental agencies, and patient advocacy groups. Background literature reviews were performed prior to the in-person meeting. A nominal group technique was employed to develop group consensus on the highest priority research gaps. Following the nominal group technique, input was solicited from all participants during the meeting, questions were iteratively focused and revised, voted on, and then ranked by importance. Results The group developed 28 separate questions. After clarification and voting, the group identified six high-priority research areas. These questions signify the perceived gaps in psychosis research in emergency settings. Questions were further grouped into two topic areas: screening and identification; and intervention and management strategies. Conclusion While psychosis has become a more common presentation in the ED, standardized screening, intervention, and outcome measurement for psychosis has not moved beyond attention to agitation management. As improved outpatient-intervention protocols are developed for treatment of psychosis, it is imperative that parallel protocols are developed for delivery in the ED setting.

Introduction: The purpose of this study was to determine if differences could be detected in the presentation patterns and admission rates among frequent emergency department users (FEDU) of an urban emergency department over a 10-year period.Methods: This was an institutional review board approved, retrospective review of all patients who presented to the ED 5 or more times for 3 distinct time periods: “year 0” 11/98–10/99, “year 5” 11/03– 10/04, and “year 10” 11/08–10/9. FEDU were grouped into those with 5–9, 10–14, 15–19, and ≥ 20 visits per year. Variables analyzed included number of visits, disposition, and insurance status. We performed comparisons using Kolmogorov-Smirnov and chi-square tests. A p<0.05 was considered significant.Results: We found a a 66% increase in FEDU patients over the decade studied, with a significant increase in both the number of FEDU in each visit frequency category over the 3 time periods (p<0.001), as well as the total number of visits by each group of FEDU (p<0.001). The proportion of FEDU visits for the 5–9 group resulting in admission increased from 25.9% to 29% from year 0 to year 10 (p<0.001), but not for the other visit groups. In comparing admission rates between FEDU groups, the admission rate for the 5–9 group was significantly higher than the ≥ 20 group for the year 5 time period (p<0.001) and the year 10 time period (p<0.001) and showed a similar trend, but not significant, at year 0 (p=0.052). The overall hospital admission rate for emergency patients over the same time span remained stable at 22–24%. The overall proportion of uninsured FEDU was stable over the decade studied, while the uninsured rate for the overall ED population for the same time periods increased.Conclusion: The results demonstrate the FEDU population is not a homogeneous group of patients. Increased attention to differences among FEDU groups is necessary in order to plan more effective interventions.