From Guidelines for Managing the Client with Intellectual Disability in the Emergency Room (© 2002)
3.1 Deciding where further assessment and treatment can, and should, take place
Consider what will be most helpful from the client's perspective (e.g., based on his or her level of functioning and need for familiarity during crises). Also consider the assessment and treatment goals. Appreciate that caregivers are not medically trained and may be apprehensive about giving medications, monitoring side-effects and managing co-existing medical problems.
There are three main options for further assessment and treatment:
3.1.1 Inpatient admission required
Consider the following when deciding about an acute psychiatric inpatient admission:
- The client needs to be medically stable. If not, he or she is not suitable for a psychiatric inpatient unit.
- If the client does not have sufficient expressive and receptive language skills to make his or her needs known, or is not independent in activities of daily living, find out if the referring agency, together with the hospital, can provide additional, needed caregiver support for the client while an inpatient.
- A behavioural disturbance is frequently the manifestation of a psychiatric disorder, and is an appropriate reason for admitting the individual for further observation.
- In planning admission, consider how you would handle a client with aggressive, self-injurious or other serious behavioural problems and whether additional support is available, such as, consultation from specialized services. (Also see Success of an inpatient admission.)
- Propose realistic treatment goals (e.g., clarification of diagnosis, stabilization, review of medications) based on a provisional psychiatric diagnosis. This provisional diagnosis would include identified target symptoms and behaviours that might be monitored in response to treatment interventions.
- Confirm with caregivers that the client when discharged will return to where he or she was living prior to the ER visit. If this is not possible, ensure that alternatives other than hospitalization have been discussed.
CAUTION: Be aware that some clients might not show any evidence, in the ER or on the inpatient unit, of symptoms and behaviours described by the caregiver. However, when leaving the structured environment of the hospital, these symptoms and behaviours may recur. This is valuable information that may only be obtained through admission.
If the client is admitted to an inpatient bed, consider how the trauma of such an admission can be reduced. Note that being admitted can be especially traumatic for lower functioning clients whose emotional and support needs may be similar to the needs of infants and younger children. Caregivers are often able and willing, with the support of their managers, to spend long periods with the client in his or her hospital environment.
Clinical experience has identified four factors resulting in a poor outcome associated with hospitalization (Sovner and DesNoyers Hurley, 1991):
- The client is prematurely discharged.
- The client is overmedicated.
- The client regresses while on the unit.
- There is poor communication between the hospital and community caregivers.
Success of an inpatient admission (in terms of meeting the client's needs and achieving assessment and treatment goals) is usually facilitated by:
- attention to inpatient routines as they affect the client. The client's caregivers can assist in adapting the hospital routine and procedures to be consistent with those in the client's home environment (e.g., how and when the client normally sleeps, how he or she engages in hygiene and other activities of daily living and how the client takes his or her medication).
- attention to the physical environment (e.g., locating the client in an end room/bed to reduce his or her distress, and to minimize possible disruption to other clients; ensuring that there is space for caregivers). If the client requires restraint, try to ensure that this is offered in a manner similar to that experienced in his or her home. Community providers should have detailed procedures for that client outlining the use of restraint (physical and PRNs,) and these protocols should be provided to hospital staff.
- attention to staffing resources to optimize the inpatient stay. It is wise to find ways to provide consistent nursing staff for the client and to identify nursing staff who can be responsible for liaising with community caregivers.
- attention to communication, as good communication with the community team and community physicians (e.g., family physician, community psychiatrist) while the client is in hospital usually contributes to a more comprehensive assessment, a more useful admission, better discharge planning and co-ordination of care, and less likelihood of repeated crises and readmissions.
3.1.2 Hospitalization not required but crisis requires an alternative environment
In the event of a situational crisis (e.g., loss of home, caregivers temporarily unable to support client), options for crisis or respite services for persons with intellectual disabilities may be available in the client's community. Identify these services in the client's area.
Note that not all communities have such options or services.
For individuals from the Toronto area, contact the Griffin Community Support Network (GCSN) at 416-222-3563 between 9 a.m. and 9 p.m. seven days a week and the Gerstein Centre at 416-929-9897 at other times.
If it is not an immediate crisis, the Gerstein Centre may link you to the GCSN the next day. The GCSN can help clients to access alternative, time-limited (1–30 days) safe beds if they are available in the community or can link you to a central respite resource.
3.1.3 Return to home environment with follow-up supports
Identify additional in-home or specialized supports for persons with intellectual disabilities available in the client's locality.
If the client lives in the Toronto area and can return home, but needs additional supports (e.g., a time-limited contract worker to get through the crisis), contact the Griffin Community Support Network (GCSN) at 416-222-3563 between 9 a.m. and 9 p.m. seven days a week and the Gerstein Centre at 416-929-9897 at other times.
If it is not an immediate crisis, the Gerstein Centre may link you to the GCSN the next day. If the client is unattached to the system, an interim case manager may be found, if available in the community, through the GCSN.