Psychotropic medications may be used to ensure safety
Psychotropic medications can be used to ensure safety during a behavioural crisis and might need to be continued during assessment of the underlying causes. This use should be temporary and ideally stopped after 72 h.309
Recommended
Expert
Behavioural crises arise from various circumstances and in response to stressors. When behaviours cannot be managed safely in the current environment, a situation can escalate to a crisis level and require assessment and management in an emergency department.
Debrief soon after emergency department visits
Debrief with the patient and caregivers as soon as possible (eg, within 72 h) after an emergency department visit in order to minimize the likelihood of recurrence. Include a review of crisis events and responses (eg, de-escalation measures, medications) and identify the possible triggers and underlying causes of the behavioural crisis.268, 311
Strongly Recommended
Ecosystem Expert
Some people with IDD who have visited emergency departments for behavioural crises do not have any follow-up with a primary care provider or psychiatrist within 30 d of discharge.310 Follow-up is crucial for continuity of care, prevention of recurrence, and the need to review any medication prescribed to manage the crisis.311
Involve emergency department staff in crisis planning
If the patient is at risk of recurrent behavioural crises, involve local emergency department staff and other stakeholders to develop a proactive, integrated crisis plan (eg, Crisis Prevention and Management Plan).315 This should be available in the emergency department and updated regularly.316
Recommended
Empirical
Hospital staff, people with IDD and caregivers consider crisis plans helpful in managing crises.312, 313 People with IDD with primary care involvement and crisis plans are less likely to visit an emergency department when a crisis arises.314
Crisis prevention and management
The Crisis prevention and management plan, Crisis prevention and Management Plan was developed by the Developmental Disabilities Primary Care Initiative at Surrey Place (Toronto, 2011). It is intended to help primary care providers and caregivers caring for agitated and aggressive patients to develop a Crisis Prevention and Management Plan. It specifies stages of escalation and recommended interventions for such patients.
Emergency Care Toolkit for Providers
Improving emergency care for adults with developmental disabilities: A toolkit for providers, developed by the Health Care Access Research and Developmental Disabilities (H-CARDD) Program provides guidance and resources for physicians, nurses, and other health care staff to improve emergency care for patients with intellectual and developmental disabilities. The toolkit includes information on preparing caregivers for emergencies.
3. Balogh RS, Wood J, Lunsky Y, Ouellette-Kuntz HMJ, Wilton AS, Cobigo V, et al. Chapter 5: Chronic disease management. In: Lunsky Y, Klein-Geltink JE, Yates EA, editors. Atlas on the primary care of adults in Ontario. Toronto: Centre for Addiction and Mental Health and Institute for Clinical Evaluative Sciences; 2013. p. 92-116.
268. Deb S, Kwok H, Bertelli M, Salvador-Carulla L, Bradley E, Torr J, et al. International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities. World Psychiatry. 2009;8(3):181-6.
309. Glover G., Bernard S., Branford D., Holland A., Strydom A. Use of medication for challenging behaviour in people with intellectual disability. British Journal of Psychiatry. 2014;205(1):6-7.
311. Bradley A, Lofchy J. Learning disability in the accident and emergency department. Advances in Psychiatric Treatment. 2005;11:45-57.
312. Bell R. Does he have sugar in his tea? communication between people with learning disabilities, their carers and hospital staff. Tizard Learning Disability Review. 2012;17(2):57-63.
313. Hemmings C, Obousy S, Craig T. Mental health crisis information for people with intellectual disabilities. Advances in Mental Health and Intellectual Disabilities. 2013;7(3):135-42.
314. Lunsky Y, Balogh R, Cairney J. Predictors of emergency department visits by persons with intellectual disability experiencing a psychiatric crisis. Psychiatr Serv. 2012;63(3):287-90.
315. Bradley E, Behavioural and Mental Health Working Group of the Developmental Disabilities Primary Care Initiative. Crisis prevention and management plan. In: Sullivan W, Developmental Disabilities Primary Care Initiative, editors. Tools for the primary care of people with developmental disabilities. Toronto: Surrey Place & MUMS Guidelines Clearing House; 2011. p. 77-81.
316. Lunsky,Y, Perry A, Lake J, and Lee, J. Improving emergency care for adults with developmental disabilities: A toolkit for providers [Website]. Toronto, ON, Canada: Portico Network, Centre of Addiction and Mental Health (CAMH). 2016. Accessed 2017 Apr 9.
