Hrev_master Abstract The phenomenon of acute behavioral disturbance is an under- recognized and potentially life-threatening syndrome, and some- times an emergency in psychiatric settings. Patients presenting to the Italian Emergency Departments (EDs) with acute behavioral disturbances account for approximately 3.2% of all ED visits. The spectrum of behaviors and of the signs overlaps with many clinical diseases. In addition to patients with behavioral problems related to mental disorders or substance abuse and toxicity, there is also a large group whose behavioral emergencies result from a medical illness. The complexity of these patients, as well as the interdisciplinary nature of their care, requires a clear and consen- sual framework for the appropriate medical management. A net- work of Italian scientific societies developed ten recommendations for good clinical practice. The main purpose is to draw up a docu- ment that presents a standardized method for the organization of the care of patients with acute behavioral disorders in EDs. Introduction The phenomenon of acute behavioral disturbance is an under- recognized and potentially life-threatening syndrome, and some- times an emergency in psychiatric settings. The spectrum of behaviors and of the signs overlaps with many clinical disease. In addition to patients with behavioral problems related to mental dis- orders or substance abuse and toxicity, there is also a large group whose behavioral emergencies result from a medical illness. In fact, various medical conditions can masquerade as psychiatric dis- orders: electrolyte and metabolic imbalance, infection, hypoxia, myocardial infarction, or cerebrovascular disease. Studies of psy- Emergency Care Journal 2022; volume 18:10609 Correspondence: Roberto Lerza, Emergency Room and Emergency Department, P.O. Levante, DEA Ospedale di Savona, Asl 2 Liguria, Piazza Sandro Pertini 10, 17100 Savona, Italy. E-mail: r.lerza@asl2.liguria.it Key words: Behavioral disturbance; psychomotor agitation; psychiatric emergency; toxicology. Conflict of interest: The authors declare no conflict of interest. CP, IC, DL, CAL, and SP are members of the editorial board of ECJ. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate: Not applicable. Informed consent: Not applicable. Received for publication: 8 May 2022. Revision received: 17 May 2022. Accepted for publication: 17 May 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10609 doi:10.4081/ecj.2022.10609 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. [Emergency Care Journal 2022; 18:10609] [page 25] Management of acute behavioral disturbance in the Emergency Department: An Italian position paper from AcEMC, CNI-SPDC, SIP-Lo, SITOX Ciro Paolillo,1 Ivo Casagranda,2 Stefano Perlini,3,4 Emi Bondi,5 Carlo Fraticelli,6 Giancarlo Cerveri,7 Fabrizio Pavone,8 Davide Lonati,9 Valeria Margherita Petrolini,9 Carlo Alessandro Locatelli,9 Roberto Lerza10 1Emergency Room, AOUI Verona-Borgo Trento, Verona; 2Adjunct Professor, University of Pavia; 3Emergency Department, Fondazione Policlinico San Matteo IRCCS, Pavia; 4Internal Medicine and Therapeutics Department, University of Pavia; 5Mental Health and Addictions Department, ASST Papa Giovanni XXIII, Bergamo; 6Mental Health and Addictions Department, ASST Lariana, Como; 7Mental Health and Addictions Department, ASST Lodi; 8Mental Health and Addictions Department, ASST Pavia; 9Toxicology Unit, Pavia Poison Centre, National Toxicology Information Centre, Laboratories of clinical and experimental toxicology, IRCCS Hospital of Pavia, Istituti Clinici Scientifici Maugeri SpA-SB, Pavia; 10Emergency Room and Emergency Department, P.O. Levante, DEA Ospedale di Savona, Asl 2 Liguria, Italy Academy of Emergency Medicine and Care (AcEMC; CP, IC, SP, RL); Italian National Coordination of Psychiatric Diagnostic and Treatment Services (Coordinamento Nazionale Italiano Servizi Psichiatrici di Diagnosi e Cura, CNI- SPDC; EB, CF); Italian Society of Psychiatry, Lombardy Region Section (Società Italiana di Psichiatria, sezione Regione Lombardia, SIP-Lo; GC, FP); Italian Society of Toxicology (Società Italiana di Tossicologia, SITOX; DL, VMP, CAL) Non -co mmerc ial us e o nly chiatric inpatients have demonstrated that approximately 50% of these have serious comorbid medical conditions.1 The Emergency Department (ED) is a gateway to care for patients with behavioral disorders. Patients presenting to the Italian EDs with acute behavioral disturbances account for approximately 3.2% of all ED visits. In elderly, the statistics are more significant: the 24% of the ED patients older than 70 is diagnosed as having delirium, and the 40% have an alteration of the mental status.2 There is a strong association between primary mental disorders and substance abuse. The number of youths admitted to EDs for acute behavioral disturbances related to drug abuse has increased of 40% in the last five years.3 Excited delirium can be associated with many psychiatric con- ditions, including schizophrenia, bipolar disorder, personality dis- orders (mainly antisocial and borderline personality disorders), general anxiety disorder, panic disorder, and major depression. The assessment of an agitated patient is complicated by several diffi- culties. The uncooperativeness and/or the inability to give a rele- vant history often force clinicians to make decisions based on very limited information. Usually, a complete psychiatric assessment cannot be completed until the patient is calm enough to participate in a psychiatric interview. A 2016 poll carried out by the Academy of Emergency Medicine and Care among doctors and nurses working in EDs highlighted a serious difficulty in knowing how to recognize a patient suffering from acute behavioral disorders and even more in knowing how to identify patients at risk of a dangerous agitation. Furthermore, about 70% of the doctors and nurses interviewed worked without a local health policy program. Moreover, the experience and content of the visits to the emer- gency room can have significant consequences on the continuity of care for the psychiatric patients. Therefore, it is important to issue recommendations for good clinical practices in the management of patients with an altered mental clinical presentation in the ED. Materials and Methods A network of Italian scientific societies (AcEMC, CNI-SPDC, SIP-Lo, SITOX) developed the present consensus. Taskforce members were identified by the boards of each scientific society. Published guidelines of national and international scientific soci- eties were reviewed.4-8 A writing group has produced a first draft of the document. To obtain a widespread consensus, the draft was distributed to the sci- entific societies for local evaluation and revision by as many experts as possible. The ensuing final draft was finally approved by all the involved scientific societies. The main purpose of the present work is to draw up a document as multidisciplinary con- sensus aimed to establish a standardized method for the manage- ment of acute behavioral disorders in ED. Endorsed items The group focused on ten items for the care of these patients: i) Clinical parity in the emergency setting for acute behavioral dis- orders; ii) Organization; iii) Management of the agitated and vio- lent patient; iv) Initial medical assessment; v) Psychiatric evalua- tion; vi) Voluntary drug poisoning/adverse drug reaction; vii) Teamwork; viii) Boarding reduction; ix) Safety care; x) Construction of a shared interdisciplinary approach. Clinical parity in emergency for acute behavioral disorders In the EDs, every subject with an acute behavioral disorder is entitled to timely access and to receive appropriate care. The behavioral emergencies must receive high-quality, multidiscipli- nary, evidence-based, and structured treatment regardless of the underlying cause (organic, psychiatric, toxicological) on par with other clinical/medical emergencies. Organization The emergency department must be prepared to receive behav- ioral emergencies by setting up adequate and equipped spaces, training staff, and promoting the taking charge by ED physicians and nurses. Early integration with psychiatrists and toxicologists (Poison Control Center) is essential, as well as with other consult- ants to be involved as needed, as well as with social services, law enforcement, and security personnel. Organization of work by teams based on the needs is desirable. Management of the agitated and violent patient The agitated and violent patient, or the patient at risk of com- mitting violence, is a critical high-risk patient due to the complex- ity of clinical and environmental management. As such, he or she should be provided with all appropriate care and assistance. Relational de-escalation interventions, pharmacological treatment (tranquilization) and, if necessary, restraint measures must be implemented early, respecting the dignity of the patient and fol- lowing specific procedures that each hospital should prepare. Initial medical assessment The medical screening (clearance) is a clinical assessment car- ried out by the Emergency Physician that aims to exclude that the acute behavioral disorder may be caused or exacerbated by an organic cause, drugs, psychoactive substances, or withdrawal con- ditions. Psychiatric evaluation The patient admitted to the emergency department for an acute psychiatric disorder is a complex patient at high risk for an unfa- vorable outcome. The psychiatrist, called to work within the team, takes charge of the interventions within his competence, promoting the coordinated, effective, and safe procedures. Voluntary drug poisoning/Adverse drug reactions The patient with suspected intoxication/adverse drugs-psy- choactive substances effect/abstinence must receive appropriate diagnosis and treatment with the help of the specialist advice of the Poison Control Center of reference, with the availability of diag- nostic tests to identify the most frequent and dangerous causative agents. Teamwork Given their complexity, the patients with acute behavioral dis- orders should be taken care of by a team of professionals consist- ing of the emergency physician, the emergency department nurse, the psychiatrist, and, possibly, the clinical toxicologist. When nec- essary, the emergency physician, based on clinical suspicion and after medical and toxicological clearance, makes use of the expert- ise of the other team members. This may happen also during the stabilization phase, with the aim to share therapeutic choices, dis- positions, and pathways. Boarding reduction The phenomenon of boarding is unacceptable for these patients because it worsens the outcome. Once stabilized, and after the need for hospitalization is shared, patients should be sent early to Emergency Special Contribution [page 26] [Emergency Care Journal 2022; 18:10609] Non -co mmerc ial us e o nly their chosen destination, reducing the time spent in the ED to the minimum. Safety of care It is a priority to ensure adequate protection of the patient, other users, operators, and the facility through collaboration with law enforcement and security personnel. Construction of a shared interdisciplinary approach It is responsibility of Health and Hospital Management to ensure shared training, procedures, structural adjustment, and organization. References 1. Gregory RJ, Nihalani ND, Rodriguez E. Medical screening in the emergency department for psychiatric admissions: a proce- dural analysis. Gen Hosp Psychiatry 2004;26:405-10. 2. Bellelli G, Morandi A, Trabucchi M, et al. Italian intersociety consensus on prevention, diagnosis, and treatment of delirium in hospitalized older persons. Eur Geriatr Med 2017;8:293-8. 3. Di Cesare M, Magliocchetti N, Romanelli M, Santori E. Rapporto salute mentale. Analisi dei dati del Sistema Informativo per la Salute Mentale (SISM). Ministero della Salute, ottobre 2021. Available from: https://www.salute.gov.it/portale/documentazione/p6_2_2_1.js p?lingua=italiano&id=3081 4. Stowell KR, Florence P, Harman HJ, et al. Psychiatric evalua- tion of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychiatric Evaluation Workgroup. West J Emerg Med 2012;13:11–6. 5. National Collaborating Centre for Nursing and Supportive Care (UK). Violence: The short-term management of dis- turbed/violent behaviour in in-patient psychiatric settings and emergency departments. London: Royal College of Nursing (UK); 2005. 6. Mental Health in the Emergency Department. Consensus state- ment. Australian College for Emergency Medicine. Available from: https://acem.org.au/Content-Sources/Advancing- Emergency-Medicine/Better-Outcomes-for-Patients/Mental- Health-in-the-Emergency-Department/Mental-Health-in-the- Emergency-Department-Consensu 7. Chauvin A, Massoubre C, Gil-Jardine C et al. Clinical practice recommendations on the management of the adult patient with psychiatric presentation in emergency facilities. [Recommandations de pratique clinique sur la prise en charge du patient adulte a ̀ preśentation psychiatrique dans les struc- tures d’urgences.] [Article in French] Ann Fr Med Urgence 2021;11:184-98. 8. Adult Psychiatric Emergencies. Policy statement of American College of Emergency Phsysicians. Ann Emerg Med 2021;77: e121-6. Emergency Special Contribution [Emergency Care Journal 2022; 18:10609] [page 27] Non -co mmerc ial us e o nly