NUBE 2024

Over the last 5 years, the Pediatric Consultation and Liaison Psychiatry Service at the C.S. Mott Children's Hospital has developed a 24/7 Social Work service that specializes in the spectrum of emergency department psychiatric services in the Children's Emergency Department. Prior to development of this service, patients had longer wait times and  multiple transitions in their care to receive a psychiatric assessment. Social work has partnered with advanced practice providers to support with psychiatric assessment, brief interventions, safety planning, coordinating psychiatric disposition, and completing post-discharge follow-up calls in the Children's Emergency Department setting. The 24/7 model was implemented in phases with close supervision, training, and partnership with medical and psychiatric providers. Additionally, emphasis was placed on utilizing a Zero Suicide approach to ensure evidence based best practices were implemented and promoted in the service. This talk will review strategies to develop a model that provides collaborative, safe, and innovative care that leverages the special skills of each profession. Development of the service also included focus on engaging non-psychiatric staff including building buy-in, care pathways, education, and utilizing a continuous learning healthcare model. Social work has a unique training and background in providing care to diverse populations and integrating culturally informed care into evaluation and intervention.

Learning Objectives:

Distinguish roles of specialty psychiatric providers in a medical emergency department.

Identify key training resources to develop staff with specialized skills to deliver psychiatric care in a medical setting.

Assess the impact of a psychiatric collaborative care model in a Children's Emergency Department.

Psychiatric assessment relies heavily on history; it is important for accurate assessment to have reliable information about a patient's past. Many times patients are unable or unwilling to provide such information themselves. Even when they do supply information, it may be incomplete or of questionable authenticity. This happens often enough to consider obtaining collateral information to get what is necessary to develop a diagnosis and treatment plan. Without such information errors may be made, with possible serious consequences. In emergency room assessments, often a decision must be made about potential dangerousness to self or others and the need for hospitalization. 

Current electronic medical records have embedded many tools to assist clinicians in providing care. Records of encounters within the institution can be easily searched. Some systems, such as Epic, have a function (in Epic's case, CareEverywhere) which can display records from other institutions. Other online sources exist, such as Prescription Drug Monitoring Programs, criminal justice docket sheets, general search engines and social media sites. Patients' insurers are also helpful sources of data, as are calls to pharmacies (often mandated by medication reconciliation requirements.) Phone calls to emergency contacts and others in a patient's life can yield vital historical and current data—whether patients must consent to such calls is debatable, and often waived if evaluation is truly emergent and care is taken not to release any information save that the patient is being evaluated.

Many laws and practices have weighed in to protect the privacy necessary for appropriate medical care, especially psychiatric and substance abuse services. In the US this is done notably by the Health Information Portability and Accountability Act (HIPAA) and Consolidated Federal Regulations Title 42 (42CFRPart 2) as well as applicable state laws. There is some confusion, as well as reasonable differences of opinion, concerning the balance between privacy and clinical imperatives.

We will present our experiences and informed opinions on the utility, bordering on necessity, of obtaining collateral information on nearly every patient assessed in an emergency setting. Legal and ethical concerns will be highlighted. Methods for doing such searches will be reviewed, as well as management of phone calls to other contacts. We will seek participation from our attendees on their use of collateral information in decision-making and work toward development of best practices for assessment.

Learning Objectives:

Describe the value added to assessment by including collateral information.

List applicable legal and ethical considerations in contacting collateral sources.

Demonstrate familiarity with searches within electronic health records and online.

Ketamine has a well-established efficacy and safety profile when used as an anesthetic agent in surgical procedures in both adults and minors. Ketamine use is being expanded to include other indications such as acute and chronic pain, complex alcohol withdrawal and alcohol use disorder, opioid use disorder, depression, and suicidality, with promising findings. Ketamine was also found to have rapid sedative effects when given to treat severe psychomotor agitation in pre-ER and ER settings, often via the intramuscular route. When it comes to severe agitation in a patient with borderline low blood pressure, heart rate, and respiration rate, almost all sedative agents, including antipsychotics, benzodiazepines, a1 antagonists, a2 agonists, and dexmedetomidine would further jeopardize the fragile vitals and may result in respiratory depression. In addition, most of these agents’ clinical effects peak after 20 to 30 minutes of administration via the intramuscular route, which can be a long time while attempting to maintain the safety of the patient, staff, and others. Ketamine, on the other hand, is found to be less likely to lead to further hemodynamic instability or respiratory depression. Additionally, the time needed to induce sedation is consistently found to be shorter when ketamine is used compared to other agents in several head-to-head clinical trials.

In this presentation, we will quickly review the mechanism of action of ketamine and discuss its indication in psychomotor agitation in pre-ER and ER settings. We will also review its efficacy and safety profile and best practices after administration.

Learning Objectives:

Understand ketamine role in treating psychomotor agitation in pre-ER and ER settings.

Explain the advantages of using ketamine in this context compared to other agents.

Appreciate best practices of medical care following ketamine use for agitation.

Working in the emergency department, often means psychiatrist will hear about trauma. In the child psychiatry world, this trauma is often abuse. As a mandated reporter, a psychiatrist is obligated to report abuse. This task can often feel daunting. It can feel daunting due to lack of understanding about the child welfare system. In addition, there is often guilt about what the child protective services (CPS) will do to the child. Hence often psychiatrists will skirt around having these difficult conversations with the child and family.
 
This session will highlighting several child protective cases. During the case presentations, it will to utilize three separate areas interviewing skills, review of common roadblocks with using child protective services, and how to use multidisciplinary teams when working with a traumatized child and to overcome the challenges when working with CPS.
 
Although each case will have elements of all three practical skill. Case one is about a child whom is not talking but there is a high suspicion of abuse. Case two involves a case where CPS is already involved but you still have concerns about their welfare and are concerned about the child going back to abuser and you are unable to contact their case worker. Case 3 involves a child that is abandoned in the emergency department. All three of these cases involve a wide variety of problem solving to help child and the emergency department/hospital needs.
 
Pooja Amin will provide a brief overview of the child welfare system. Pooja Amin and Dr Meghan Schott, will provide an overview of the cases. Finally, Dr Schott, a child and adolescent psychiatrist will share her experiences of serving on DC’s citizen review panel, a federally required entity for each state to review child protective services.

Learning Objectives:

Equip participants with effective interviewing techniques and communication strategies to help children feel safe and comfortable discussing their experiences with ongoing abuse.

Enable participants to identify common roadblocks in working with Child Protective Services (CPS) and develop strategies to effectively navigate these challenges.

Explore the roles of various professionals (e.g., social workers, psychologists, legal representatives) in managing and supporting child abuse cases within the emergency psychiatry setting.

Objective: This scoping review aims to summarize the current state of research literature on the management of agitation and aggression in the care of youth with Autism Spectrum Disorder (ASD) in the emergency department (ED). Clinical guidance for the management of agitation in this patient population will be outlined.

Method: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for scoping reviews searching PubMed and PsycINFO databases (May 1, 2013 through July 24, 2024) for studies that reported management of agitation or aggression in the care of youth with ASD in the ED.

Results: Management of agitation and aggression in the care of youth with ASD in the emergency department has been documented. Approaches include beginning with a rapid assessment and functional behavioral assessment. There exists a typical differential diagnosis followed by non-pharmacologic and pharmacologic treatment strategies. Restraint and inpatient psychiatric hospitalization are discussed.

Conclusion: There exists a growing literature on the management of agitation and aggression in the care of youth with ASD in the ED. Recommendations for the management of this patient population in the ED are outlined.

Learning Objectives:

Attendees will understand the current evidence base for the management of agitation of pediatric patients with ASD in the ED.

Attendees will understand clinical recommendations for the management of agitation in pediatric patients with ASD.

Attendees will learn how to integrate both non-pharmacologic and pharmacologic strategies for managing agitation in pediatric patients with ASD in the ED.

When most physicians hear the term “negotiation”, they immediately imagine an adversarial process…..typically tied to contracts, employment agreements, or payer partnerships.  This brief session is meant to note an alternative view of this term that is actually VERY much in line with the ethos and mission of those administering emergency psychiatric interviews.

This conversation will note how there are innate components of the negotiation process that not only are already in use by AAEP members but also strategies that (once consciously noted) can be maximized to the benefit of both the professional and the patient.

Inherent in this will be discussion of how this approach embraces a principle approach that is non-judgmental, non-adversarial, and rooted in compromise and partnership. Additionally, we will proffer the five types of active listening…with the goal of moving our daily work from levels 1-2 to level 5!

By examining all of the above, the attendees will be able to have a “rapid fire” approach on what they are doing well in their interview processes….and what can be improved/enhanced. Inherent in this will be a better understanding of utilizing and maximizing the tenets of actual negotiation!

Learning Objectives:

Examine what "negotiation" actually represents while removing any adversarial nature attributed to this term.

Provide clear examples of how negotiation principles can benefit engagement and outcomes when interviewing individuals in crisis.

Manifest how negotiation philosophy can relate directly to the field of emergency psychiatry, as it emphasizes interventions that are non-judgmental, non-dichotomous, and welcome to compromise/amendment.

Behavioral emergencies often occur in high-stress environments, where immediate and effective intervention is crucial. Traditional emergency response methods may inadvertently retraumatize individuals who have experienced trauma. Trauma-informed care (TIC) prioritizes the safety, trust, and empowerment of patients, ensuring interventions are sensitive to the effects of trauma.

This presentation explores the core principles and practical implementation of trauma-informed care in emergency settings. Key principles such as safety, trustworthiness, peer support, collaboration, and empowerment will be highlighted. We will discuss strategies for training emergency responders, assessing trauma, and implementing immediate interventions.

Through a case study, we will demonstrate the real-world application and effectiveness of trauma-informed approaches, showcasing their positive impact on patient outcomes. This session aims to equip mental health counselors and emergency responders with the knowledge and tools necessary to enhance the overall response to behavioral emergencies.

Learning Objectives:

Participants will be able to define trauma-informed care and identify its key principles, including safety, trustworthiness, peer support, collaboration, empowerment, and cultural sensitivity, and understand how these principles can be applied in emergency response situations to enhance patient outcomes..

Participants will learn specific techniques and interventions for assessing and managing trauma in emergency settings, including immediate stabilization methods, effective communication strategies, and tools for screening and assessing trauma. They will also gain insights into training and educating emergency responders to integrate trauma-informed care into their practice.

Participants will analyze real-world case studies that demonstrate the application and effectiveness of trauma-informed care in emergency situations. They will be able to identify successful interventions, understand the challenges faced, and apply these lessons to their own practice to improve patient outcomes and reduce the risk of retraumatization.

Interdisciplinary collaboration can be a complex process that requires time, patience, and understanding of the different points of view and training of each discipline. People working within healthcare often share core values but are often trained in isolation from the other disciplines. Professional silos can occur as each discipline focuses on what they can offer in terms of patient care and staff supports but a strong adherence to “staying in our lane” can also hinder opportunities for shared teaching, case conceptualization, interdisciplinary team responses in crisis. Solid interdisciplinary teamwork is even more challenging when members of the team change frequently, such as who responds to a crisis, staff covering the shift, or rotating attending physicians.

A panel of Directors in safety and security, nursing, and psychiatry and nurse management will describe their collaborative leadership process when navigating serious and complex issues relating to patient and staff safety for inpatient psychiatry and emergency medicine. As a tertiary level hospital in a primarily rural state, complexity of patient needs, recruiting trained staff in a time of extensive staff shortages, and identification of resources are consistent challenges. The team will describe a crisis stabilization unit (CSU) that was developed as a way to meet the needs for patients diagnosed with psychiatric illnesses who experience long waits in the emergency, require increased resources and support, and historically not receiving mental health treatment while they wait for a bed. The presentation will describe the development of two unique staff positions within nursing and safety and security and the successful integration of these staff members on inpatient psychiatry and emergency medicine. Research on interdisciplinary teams in healthcare and use of simulation-based training (e.g., Engum & Jefferies, 2012; Saragih, et al., 2024) provided guidance for development and expansion of training for frontline staff in safety and security and nursing who are responsible for crisis responses and prevention of dangerous behavioral episodes. Discussion will review of challenges, barriers, and the concept of transdisciplinary teams to meet complex patient needs and staff safety.

Learning Objectives:

Participants will understand strategies to support interdisciplinary leadership collaboration for cross training emergency response teams.

Participants will learn about the development of unique staff positions to address staffing shortages and complex patient needs.

Participants will understand the difference between an interdisciplinary and a transdisciplinary process as it relates to developing skilled core response teams.

Political ideology and beliefs are rarely illegal and seldom relevant in psychiatric emergency care. Nonetheless, security and intelligence professionals are increasingly recognizing that ideologically motivated violence is a leading threat. From skirmishes at public protests, to threats against public health leaders and poll workers, to insurrection, incidents both isolated and expansive are increasingly coming under public scrutiny. And as law enforcement agencies do a better job of embracing multidisciplinary strategies like behavioral threat assessment and management, This presentation will provide a basic overview of what is known about ideologically motivated violence in the United States and provide practical guidance for PES clinicians in evaluating and understanding people at the intersection of violence risk and extreme ideological beliefs.

First, clinicians must be able to carefully navigate potentially fraught discussions about political ideology in clinical settings. There has long been an opprobrium about discussing politics in the workplace. Delving deeply into political beliefs in behavioral health settings is complex and perilous, with notable risk of transference and countertransference leading to disruptions in the therapeutic alliance. Practical guidance on navigating these turbulent waters will be offered.
Second, clinicians need to understand that the overlap between political extremism and violence risk is small and nuanced. Extremist ideology may be incidentally noted during an evaluation or the ideology may be expressly linked to violent threats or behavior as the primary cause for evaluation. While the adage to use individualized assessment and individualized treatment plans holds true for people with extremist beliefs there are specific considerations which will be discussed pertinent to evaluation of people which apply in the evaluation and management of violence risk.

Third, considerations related to clinical and administrative decision-making will be explored. Just as law enforcement is increasingly partnering with behavioral health and social services for threat management cases, so too do we need to reach out in the management of our high-risk cases. Identifying psychiatric illnesses and social stressors amenable to clinical interventions is critical. Peer supports for hate-based ideologies and for parents of people with extremist ideologies may be available in some regions. In some cases, people who are ambivalent about continued engagement with extremist organizations may respond well to CBT and RET even in the absence of other psychopathologies.
Case examples, critical terminology, and guidance for building both ad hoc and lasting productive partnerships between clinical services and law enforcement partners will be woven throughout the presentation.

Learning Objectives:

Assess risk factors for violence relevant for people with strong political and ideological beliefs.

Formulate strategies for consultation and documentation in high risk clinical cases.

Develop personal strategies to recognize and mitigate personal and organizational countertransference.

In Malaysia, Dutch botanist Pieter Korthals in 1831 first discovered Kratom or Mitragyna speciosia. Kratom is derived from the Nitragyna speciose korth, a tropical forest tree found in Malaysia, Thailand and Myanmar. The trees’ leaves contain psychoactive opioid compounds, that have been consumed for thousands of years. Kratom contains alkaloids that bind to opioid receptors, with an opioid drug structure.

Kratom can be ingested in various routes, traditionally chewed but also smoked or strained in teas. The leaves have a very bitter taste that can be masked by adding sugar or honey in juices or teas. As an alternative, lemon juice can be added to facilitate the extraction of the plant alkaloids.

Kratom induces euphoria, and in lower doses acts as a stimulant, increasing energy, alertness, while in higher doses it induces sedation. Kratom is purportedly used for anxiety, depression, inflammation, libido. Importantly, given opioid activity, it suppresses opioid withdrawal. With regular use, Kratom is associated with dependence and addiction.
Kratom’s pharmacological properties are similar to those of opioids but unlike opioids it is not a federally regulated substance. There are increasing number of case reports with Kratom intoxications and withdrawals that are challenging for the physicians. Kratom is not a very commonly known substance and is also difficult to detect as it does not cause positive findings in urine drug screens. The assessment relies on the history from the patient or specific immune-assay tests. The treatment can consist of symptomatic treatment with Clonidine but also with Suboxone. There are several cases reported of Kratom withdrawal.

Kratom is gaining increasingly popularity and about 40 million Americans are current using Kratom recreationally. However, there are currently very limited clinical studies available that demonstrate safety and efficacy in humans. The FDA has not approved Kratom for any medical use, and publishes warnings regarding its toxicity. Available information is mostly based on reports from users or animal models. Case reports involving the use of Kratom are concerning and alarming. The use of Kratom is associated with increasing numbers of ER visits, calls to poison control centers and even deaths related to multiple causes.

This presentation is based on a systematic review of literature of the current available data on Kratom and will be providing physician and clinician education about Kratom as a substance.

Utilized sources were Pubmed, Ovid, Medline, PsychInfo, EMBASE.

Learning objectives:

Kratom use- Clinical presentations, toxicity, risks.

Pharmacology of Kratom.

Kratom use- Diagnosis and Treatment

Precipitated opioid withdrawal is an abrupt onset of severe withdrawal symptoms after administration of full or partial mu antagonists.  This clinical case series and skill building workshop will elucidate options for management of precipitated opioid withdrawal in the emergency department.  Precipitated withdrawal can lead to symptoms from piloerection, nausea, vomiting and diarrhea to delirium and critical illness.  This series will look at 3 different patient scenarios to help guide clinicians in providing critical care for patients in acute precipitated withdrawal.  The fear of this complication and challenges managing precipitated withdrawal can be a barrier for some providers in starting buprenorphine.  Education around how to manage precipitated withdrawal can assist clinicians in increasing their comfort with buprenorphine initiation.

The patient scenarios involve precipitated opioid withdrawal with naloxone and buprenorphine administration in the ED and in the community. Clinicians will have increasing comfort in assessing patients Clinical Opioid Withdrawal Score (COWS) as well as immediate management of withdrawal symptoms.

Patient #1 has initiated buprenorphine through a home start and is presenting to the ED with worsening symptoms of withdrawal.

Patient #2 received naloxone by EMS in the field after unintentional opioid overdose and presents to ED with signs of precipitated withdrawal.

Patient #3 was started on buprenorphine in the ED and has rising COWS despite maximizing buprenorphine dosing.

This presentation will discuss using multimodal agents including buprenorphine (IV, SL and patches), benzodiazepines, ketamine, anti-dopaminergic agents and full agonist opioids for management of opioid withdrawal symptoms. The clinical scenarios, patient characteristics, risk factors for precipitated withdrawal and patient outcomes as well as follow up care will be discussed. Clinicians can utilize these skills to improve care for patients and gain confidence in starting medication assisted treatment in the emergency department.

Learning Objectives:

Recognizing precipitated opioid withdrawal.

Treating precipitated opioid withdrawal with multimodal agents.

Increasing confidence to initiate buprenorphine treatment for opioid withdrawal safely in the ED.

Frequently, patients present with psychiatric symptoms and turn out to have a medical etiology. Many of these medical mimics are commonly known such as hypoglycemia and myxedema coma but some are less common which makes them more difficult to diagnosis and manage.  This course will focus on some of the less common etiologies of such psychiatric presentations including catatonia and NMDA receptor antagonist. Evaluation and treatment in the emergency department using case presentations.

Learning Objectives:

To list non-traditional causes for patient presenting with psychotic features or depression symptoms.

To describe the lorazepam challenge for patients with catatonia and expected outcome.

To define procedures needed to determine a definitive etiology for rare medical mimics.

Cannabis and cannabis derivates are enjoying wide popularity in the U.S. While many developments came to a hold during the Covid-19 pandemic, the legalization of cannabis further progressed along with an expanding market for Delta-THC.

Cannabis is federally a schedule 1 substance but hemp derivates are exempt from this law through the 2018 Farm Bill. The substances classified as hemp derivates include the Delta-THC and CBD. Due to this legal loophole, they are easily accessible and sold at local convenience stores, gas stations or online. The sales of Delta-THC in the last 2 years have exceeded over 2 billion dollars.

The most used Delta-THC are Delta-8-, 9- and 10-THC. Delta-THC’s effects are similar to marijuana as they induce euphoria, feeling stoned and can cause anxiety and psychosis. The effects on cognitive alertness differ as Delta-8 -and 9-THC are sedating while Delta-10-THC is rather activating. Altered sense of time as well as short-term memory deficits and poor concentration are associated with any of the Delta-THC. In addition, cardiovascular effects including tachycardia and hypertension have been reported.

Legally, the THC content of these substances is supposed to be less than 0.3% THC. The majority of Delta-THC do not undergo any laboratory testing prior to marketing. Conducted tests of products have shown discrepancies with worrisome results with deviations from the claimed content on the label by up to 150%.

There is no standardized method established to synthesize Delta-THC. Chemically, the Delta-THC are molecularly close relatives. First, manufacturers must extract CBD from hemp and then convert it to psychoactive cannabinoids. For this chemical synthesis process, unsafe household chemicals are frequently used. Those potentially leave residual substances in the Delta-THC, so that the substance can contain toxic solvents, for example acetone, heavy metals, or lead. These toxic byproducts can lead to harm in the user and potentially cause lung damage if smoked or vaped.
Along with the increasing popularity of Delta-THC, there are also increasing cases of toxicity being reported. During the time between January 2021 and February 2022, the DFA (U.S. Food and Drug Administration) reported over 2,300 calls to national poison control centers. Every third person who called poison control required a medical evaluation in a hospital setting, while one person required an inpatient admission. Due to these safety concerns, seventeen states have banned the sales of Delta-8-THC while seven others have restrictions in place.

This presentation is a systematic review of literature discussing the available data on Delta-THC for psychiatric and medical use. Utilized sources were Pubmed, Ovid, Medline, PsychInfo, EMBASE.

Learning Objectives:

Policy of Delta-THC, Legal aspects.

Effects of Delta THC use.

Toxicity of Delta THC.

From the discovery of NMDA encephalitis by Josep Dalmau in 2007, autoimmune encephalitis has become an ever expanding group of diseases that is durably changing the landscape of modern neurosciences. These syndromes can initially present with acute or subacute behavior changes sometimes overshadowing subtle neurologic symptoms such as movement disorders or seizures. There is a variety of scenario in which patients with autoimmune encephalitis can, at least initially, be mistaken for patients with primary psychiatric diagnosis. While novel therapeutic approaches have greatly improved outcomes of patients with autoimmune encephalitis, delay in diagnosis remains a major obstacle. As the knowledge around autoimmune encephalitis continues to progress, first line clinicians should be more and more familiar with the specificities of this group of disease in order to close the gap between onset of symptoms and adequate treatment.

This presentation will feature:

1. Basic neuroscientific concepts and outline of the latest discoveries in autoimmune encephalitis such as mechanism of autoantibodies (intracellular vs extracellular; effector vs biological marker), pathogenesis (infectious triggers, paraneoplastic syndromes).
2. Main syndromes and their clinical presentation with emphasis on behavioral symptoms through clinic vignettes.
3. Simplified diagnostic algorithm and decision tree, adapted from the 2016 consensus clinical criteria of autoimmune encephalitis. 
4. Symptomatic management of psychiatric symptoms presented by patients with autoimmune encephalitis and the difference with classic management. 
5. Outline of the neurologic workup: who needs an MRI, an EEG, CSF analysis, malignancy workup. 
6. Outline of the management of autoimmune encephalitis.
7. Recovery and residual psychiatric symptoms and their management. 
8. Future considerations: will an autoimmune panel be sent for every patient in the psychiatric emergency room

Learning Objectives:

Recognize atypical presentations of behavioral emergencies that could suggest an autoimmune encephalitis.

Be familiar with the main autoimmune encephalitis syndromes and their mechanisms.

Know the outline of the workup, treatment, and psychiatric symptomatic management of autoimmune encephalitis.

Acetaminophen overdose is a potentially fatal clinical syndrome, warranting prompt and accurate assessment and clinical care. Acetaminophen toxicity can occur from acute ingestion, or chronic use over time. Though this talk focuses on acute hepatic consequences of overdose, inadvertent exposure over time often has a worse prognosis due to later recognition and treatment. The acute toxidrome has 4 stages, whereby stage 2 is what appears to be a resolving syndrome. However, if unrecognized, this may progress to severe hepatotoxicity and death. An Acetaminophen level 4 hours after the overdose that is greater than 150 mcg/mL warrants urgent initiation of the antidote N-Acetylcysteine and inpatient hospitalization.

Acetaminophen pharmacology is critical to treatment. Toxicity occurs when the body's innate metabolic pathways are saturated, causing build-up of a toxic metabolite which binds to hepatocytes, leading to liver injury and fatality. N-Acetylcysteine treatment enhances the clearance of the toxic metabolite, and should be promptly started. There are specific protocols for oral and for IV management. Astute and correct treatment has high success rates, though serious complications may result. In cases where Acute Liver Failure occurs, there is a high mortality rate, and 1/3 of patients will require a liver transplant. Fortunately, if N-Acetylcysteine is given within 8-10 hours after the overdose, serious hepatotoxicity is uncommon and death is extremely rare, regardless of the initial serum concentration.

Learning Objectives:

An appreciation of the emergent nature of Acetaminophen overdose.

Using the serum Acetaminophen level to decide when to treat.

Proper use of the antidote N-Acetylcysteine.

Daniel Kahneman’s Nobel prize winning research, on behavioral economics, established how humans often make snap decision that often defy logic. Physicians are no different. Emergency physicians are, in fact, more likely to use “fast thinking” compared to other physicians. This is in part due to needing to make quick decisions based off a triage model on a large volume of patients. However, this can create a bias in how we diagnosis and treat patients.

Bias can occur through implicit bias or subconscious perceptions. These often include unconscious feelings about something one cannot control like race, gender, and weight. Microaggressions are often subconscious buy can also be conscious and often reflect biases in the form of words and gestures. Emergency psychiatry has its own form of microaggressions by using words like “boarder,” “borderline,” and “frequent flyer.” Although these terms might help the physician segment medicine’s harsh realities, it paints the patient in a negative light, leading to poorer quality of care. This presentation will look at things like implicit bias and microaggressions that can occur during an interview by utilizing research from both the diversity, equity, and inclusion (DEI) and psychiatry fields.

However bias is not always subconscious. Chart checking is an invaluable tool that can inform decision making based on past events. When one relies to much on past history rather than current presentation, this can lead to bad outcomes for our patients. Unfortunately, one may never know when a potential negative event occurs in the emergency department since it will occur out of sight and hence a confirmation bias occurs.

The psychiatric interview is a unique skill that goes beyond the traditional subjective, objective, assessment, plan (SOAP) note. During training we teach students, residents, and fellows the art of the psychiatric interview but often do not reassess our own interviewing skills. However, since the interview is highly subjective itself, it leads to more bias compared to other components of medicine. How does one retrain oneself to the level of naivety of first year medical students, while still retaining the knowledge of a season attending?

This presentation will begin by providing a brief overview of the history of bias in medicine with more of a focus on psychiatry and basic DEI principles. Next the speakers will share real life examples of when medicine have failed in emergency psychiatry due to an overreliance on chart checking. The speakers will also discuss their own personal mental health journeys where bias has come into play in their treatment. Finally, it will conclude with how one can look at the art of interviewing and try to remove bias as much as possible by providing real world clinical skills.

Learning Objectives:

Define implicit bias and microaggression.

Understand how mircoagressions and other forms of bias are used in everyday settings including mental health.

Utilize interviewing skills to help eliminate common points of bias during clinical interviews.

The goal of this presentation is to propose a framework for conceptualizing adolescent social media use behavior that relies on a functions-based approach. We will describe an algorithm for eliciting a social media use history that focuses on evaluating function-specific behaviors and interactions and assess for related risk and resilience factors.

Background: 
Social media (SM) use among adolescents soared over the past decade, raising questions and concerns about its impact on youth mental health. While research points to a correlation between this rise and negative mental health outcomes, there is a paucity of literature discussing approaches to screen for SM use and assess for associated risk and resilience factors. The problem with available screening assessments is that they rely on specific knowledge of the applications. The issue with this is that SM applications cycle rapidly, making it difficult to keep up. Previous practices focused on “screen time” as a measure for SM use. However, recently, some researchers have advocated for a more nuanced, multi-dimensional approach that highlights “how” and “why” adolescents use SM. In this poster, we propose a framework for identifying “use types” that satisfies this nuanced model, focusing primarily on the function of SM use, and evaluating risk and resilience factors associated with each use type.

Methods: 
A literature survey was conducted to identify variables of SM use such as type of engagement and type of online interactions, paying particular attention to risk and resilience factors associated with each category of use. We describe a function-based algorithm that attempts to provide direct clinical guidance on how to conduct the SM use segment of the psychiatric interview without requiring extensive knowledge of the applications used by adolescents. To do that, we focused our framework on 5 main SM functions: social networking, image sharing, video sharing, direct messaging, and streaming.

Results: 
When examining the literature, we identified two major parameters describing adolescents' engagement with SM. First, is the type of use, categorized into consumption and contribution. Second, is the type of interactions, divided into public and private. Recognizing these parameters, we created an algorithm that focuses on eliciting SM use history by asking three major questions: “What function are they using? How are they using SM? And Who are adolescents engaging with on SM?”. By combining type of use with type of interactions, we were able to identify four general use types: private consumption, private contribution, public consumption, and public contribution. We then identified risk and resilience factors associated with each use type found in the literature.

Conclusions: SM use has become a fixture in the life of adolescents. Due to the significant role it plays and the implications of its use during this phase of development, it is imperative that child psychiatrists are able to accurately evaluate use and assess for risk and resilience factors associated with it. Using our framework, clinicians can assess the adolescent’s SM use and understand both their risk and resilience factors without relying on prior application knowledge.

Learning Objectives:

Learn how social media consumption and contribution behavior can be elicited and formulated during a psychiatric interview.

Learn how public vs private interactions impact adolescent mental health and how to ask about these interactions in a psychiatric interview.

Develop an assessment of the adolescent’s social media use type and explore possible protective and risk factors.

Has this happened to you? You are on busy shift and have just admitted an 88-year-old patient to the hospital because the family says that caring for patient at home “has become too much.”  As you walk into the next room, you see that your new patient is also in her 80’s and has dementia.  The patient looks amazing, but the daughter who cares for her looks exhausted and depressed.  How long will it be before this caregiver is also overwhelmed?  You realize that the best thing you could do to help the patient is to help the caregiver.  But what can you do?

In this dynamic, case-based lecture, we will explore the issues related to Caregiver Stress and Burnout among those who care for older adults. We will offer practical tips aimed at healthcare providers who encounter the impacts of caregiver stress in the clinical setting but who may not feel equipped to help. As faculty from Geriatrics and Emergency Medicine, we will share insights drawn from the literature as well as from experiences in our ACEP Level 1 Accredited Geriatric Emergency Department.

Learning Objectives:

By the end of this lecture, the audience will understand:

• What caregiver stress and burnout are and how they impact both sides of the patient-caregiver dyad.
• How to identify caregiver stress and burnout, including how to use clinical screening tools to find cases that might go unrecognized.
• How to make effective recommendations and interventions to help caregivers who are experiencing stress and burnout as they try to meet the increasing needs of loved ones at home.

Richard deShazo (2018) writes about  "…the unfortunate role and responsibility of organized American medicine in past and present health disparities in our country." A long history of slavery, racism and mass incarceration in the US continue to rear their pernicious heads in how we provide health care to minoritized and marginalized communities in particular.  Racial and ethnic bias have a habit of showing up stronger and often unconsciously in situations of stress, ambiguity, and time pressure.  As such, health and mental healthcare practitioners who work under these conditions in urgent and emergency care settings are susceptible to misperceptions that can lead to unequal treatment and medical error.  In fact, the National Standards for Culturally and Linguistically Appropriate Services (CLAS STANDARDS) were developed in 2001 and revised in 2013 by the Office of Minority Health specifically to provide guidance for health care administrators and practitioners to rectify these inequalities.  This is the imperative of health justice and equity in medicine and behavioral health.

This interactive and participatory session will draw from humanities and poetry to highlight the pernicious nature of bias and to illuminate the psychological, interpersonal and organizational challenges at hand. The session aims to help participants understand the perils of stereotyping in clinical settings, and will provide tangible tools and strategies for enhancing awareness. understanding, and communication skill development towards greater health equity, and practitioner and patient satisfaction with care. Moreover we will explore the power and importance of assertive and empowering communication approaches towards equity in patient advocacy. The presentation will focus on both practitioner awareness and skill development, as well as taking an organizational and healthcare team perspective on transforming how care is delivered toward the elimination of health inequities and the enhancement of health justice.

Learning Objectives:

By the conclusion of this presentation, participants will deepen their understanding of the role of bias and stereotyping in health inequities.

By the conclusion of this presentation, participants will deepen their self-reflection on biased communication with patients and family members in acute behavioral and emergency settings.

By the conclusion of this presentation, participants will grow their capacity for assertive communication in helping colleagues and team members remain accountable to the CLAS Standards of culturally and linguistically appropriate services in clinical settings.

The imposter phenomenon (IP) is a negative state of self-doubt experienced by various professions, genders, and races, with a prevalence rate reported from 9-82%. If you were to do a quick internet search, there are numerous TED Talks, social media sites, and business professional literature dedicated to exploring and explaining IP. In emergency psychiatry, IP can surface in a variety of forms: as a contributor to/direct source of distress in patients, burnout in trainees, or stunted professional growth with experienced staff. IP has been psychiatrically linked with depression and anxiety, and those who experience it may struggle with personal relationships and/or marital distress. In the workplace, leaders and administrators need to recognize and address IP as it is linked to turnover, procrastination, and inability for managers and supervisors to appropriately delegate. In academic settings, IP causes more subjective distress in non-white groups than stress that comes from racial discrimination. Despite these many negative outcomes, IP does not easily fit into a diagnostic category, and so it is not always discussed or taught in an academic setting (outside of perhaps a lecture in medical school). However, because of the risk that IP can pose to anyone, at any point in one's career, and because of its prominence in popular culture, it is imperative that we are able to identify and address IP in our patients, our peers, our colleagues, and ourselves. This talk will provide an academic overview of this concept, risks for developing it, signs to identify it, ways to combat it, and how to psychiatrically treat it in therapy. Based off of a 2020 ACGME small group discussion outline, an experiential component ("think-pair-share") will be utilized to engage the audience in active learning. Popular media clips will be incorporated to capture the audience's attention, and when possible, the audience will be encouraged to share their own experiences in dealing with IP or caring for patients who are suffering from IP. Supervisors will also be given information on how to address IP with trainees using the ACGME recommendations.

Learning Objectives:

At the end of the presentation, the audience will be able to define imposter phenomena, prevalence, and negative outcomes from it.

At the end of the presentation, the audience will be able to list 2 risk factors for experiencing imposter phenomena.

At the end of the presentation, the audience will be able to list 3 interventions to combat imposter phenomena.

When errors are made in the practice of medicine the results can be devastating. Unfortunately, errors are all to common. It is estimated that hundreds of thousands of patients die each year as a result of medical error, and medical error might be the third leading cause of death in the US, behind only heart disease and cancer.  Commonly cited risks for making errors are high workload, time pressure, multitasking, and multiple handoffs- all things that are extremely common in emergency psychiatry!   Caring for patients with mental illness in crisis can certainly leave one prone to mistakes. Behavioral health patients in emergency departments have a longer length of stay, often causing their care to run over several shift, increasing the risk of handoff errors.  When mistakes are made in the care of patient in emergency psychiatry the results could not only cause immediate harm to the patients, or to the community, but can also have a long-lasting effect eroding the trust in a medical system that could provide them with help.  We will review the type of errors that are common in the field of emergency psychiatry through several case reviews, and spend the final half of the presentation discussing the recovery process.  We will review the literature and common practice around the responses to errors. We will look at the individual responses, with patients, with staff and with families, as well as systemic approaches to responding to errors. We will discuss some error prevention techniques that can easily be implemented in emergency departments.

Learning Objectives:

Attendees will be able to identify common causes for errors in the medical setting.

Attendees will learn skills for navigating responses to medical errors.

Attendees will learn techniques for error prevention in the emergency psychiatry setting.