Any psychiatric assessment of a drowsy patient must be preliminary

Dear Editor,

In February 2024, the NSW Clinical Excellence Commission released a widely distributed ‘Safety Information Broadcast’ concerning the assessment of intoxicated patients in the emergency department. A bullet point in the one-pager states ¹ :

Assessment of a patient who is drowsy can still provide valuable information for planning mental and physical health management.

This phrasing is ambiguous and likely to cause confusion. It can be, and has been, interpreted to mean that psychiatrists should not delay comprehensive psychiatric assessments of patients simply because they are heavily intoxicated.

Significant intoxication per se does not prohibit a preliminary psychiatric assessment. However, significant intoxication will impair a patient’s recall, judgement and reasoning and will mask mental state abnormalities that might become evident and crucial to clinical decision-making, when the patient is no longer intoxicated. Clearly, it is poor practice to conduct a psychiatric assessment, for the purpose of deciding upon disposition, of a person who is significantly substance-affected. It is likely that this safety broadcast will lead to premature requests for detailed specialised psychiatric assessment that, ironically, will promote unsafe practice.

If concerns are raised about an intoxicated patient being suicidal, then, depending on local workflow arrangements, these could be discussed with psychiatric clinicians, as might questions regarding the use of the Mental Health Act or the management of behavioural or severe emotional disturbance.

This letter to the Journal, widely endorsed by members of the Emergency Psychiatry Network (EPN), represents what we hold to be a bulwark for safe practice and timely care. It might also be used as evidence to demonstrate competent professional practice in future legal action.

Government broadcasts carry a degree of gravitas that can be interpreted as authoritative by administrators. They will also carry significant weight with the courts. In this particular case, the EPN fears there is risk of the document bringing unintended consequences to the patient, psychiatrist, Emergency Department and the broader hospital system. There are also significant risks associated with formulating general safety advice on the basis of single critical incidents.

The EPN is of the opinion that this Broadcast is ambiguous and could lead to practice detrimental to patient care by promoting the idea that a full psychiatric assessment is possible when patients are intoxicated. The document should be immediately withdrawn.