Acute Psychiatric Care Advancements

2024-2025 Evidence-Based Clinical Protocols

Executive Summary

  • Shift from "containment" to "active treatment" model
  • C-SSRS and ASQ for suicide risk stratification
  • BVC for violence risk (Score >2 = high risk)
  • SMART Medical Clearance replaces routine testing
  • Project BETA for agitation management

Risk Assessment Tools

Suicide Risk: C-SSRS

Distinguishes passive ideation from active intent with plan. Task-shifting to nursing staff improves ED throughput.

Violence Risk: Brøset Violence Checklist

ScoreRiskAction
0SmallStandard care
1-2ModeratePreventive measures
>2High/Very HighManagement plan

SMART Medical Clearance

Replaces "medical clearance" (implying no issues) with "medical stability for psychiatric admission."

  1. Vital signs within parameters (HR <110, BP <180/110, Temp <100.4°F, O2 >94%)
  2. No history of new-onset psychosis, active illness, trauma
  3. Alert and oriented; no toxidrome or neuro deficit

If all negative: No further labs required.

Agitation Management: Project BETA

Verbal De-escalation (10 Domains)

  1. Respect personal space
  2. Do not be provocative
  3. Establish verbal contact (one leader)
  4. Be concise
  5. Identify wants and feelings
  6. Listen closely
  7. Agree or agree to disagree
  8. Set clear limits
  9. Offer choices
  10. Debrief

Pharmacologic Stepped Approach

StatusInterventionMedication
CooperativeOral (PO/ODT)Risperidone 1-2mg, Olanzapine 5-10mg ODT
UncooperativeIMDroperidol 2.5-5mg (preferred), Olanzapine 5-10mg
RefractoryDissociativeKetamine 4-5mg/kg IM

Withdrawal Protocols

Alcohol Withdrawal: Phenobarbital

Superior to benzodiazepines. Loading dose 10mg/kg IV (IBW) over 30 minutes. Auto-tapers over days.

Opioid Withdrawal: Buprenorphine Macrodosing

8-16mg SL initially; repeat at 60 minutes if symptoms persist. Rapid receptor saturation bridges to outpatient care.

Acute Rigid Patient Differential

FeatureNMSSerotonin SyndromeCatatonia
CauseD2 antagonistsSerotonergicsPsychiatric illness/BZD withdrawal
OnsetSlow (days-weeks)Rapid (<24h)Variable
Muscle"Lead pipe" rigidityHyperreflexia, clonusWaxy flexibility
TestCK elevatedHunter CriteriaLorazepam challenge
TxStop agent, dantroleneStop agent, cyproheptadineLorazepam, ECT