Emergency mental-health assessment and disposition — OSCE risk-assessment and disposition station

Station objectives

1. Perform a rapid safety and medical screen and exclude an organic or toxicological driver. [4] [7]
2. Conduct a structured suicide-risk assessment using a validated brief screen and synthesise a risk stratum. [1] [3]
3. Match the level of care to the risk stratum, applying the least-restrictive principle. [7] [5]
4. Build a safety plan with means-restriction counselling and a confirmed follow-up. [6] [5]
5. Manage intoxication and capacity and apply local mental-health statute appropriately. [4] [7]

Candidate brief

You are the paediatric doctor in the emergency department. You have 8 minutes for Station A (a 15-year-old girl two hours after a paracetamol overdose, alert and stable, with more tablets at home and a previous overdose) and 10 minutes for Station B (a presentation in intoxication where the candidate must manage the medical screen, the limits of an intoxicated risk assessment, a capacity question and a disposition with a safety-net). Examiners score the rapid medical screen, the structured risk assessment with a validated tool, the risk synthesis, the matched disposition, the safety plan with means restriction, and the statutory and follow-up reasoning. [1] [7]

Station A — Overdose: structured assessment and disposition

Setup: A 15-year-old girl is brought in by her mother two hours after taking twelve paracetamol tablets. She is alert and haemodynamically stable. She says her boyfriend ended the relationship today and she 'wanted it to stop'. There are more tablets at home and she had one previous overdose six months ago. [7] [5]

Expected actions:

• Perform the rapid medical screen: vital signs, capillary glucose, focused exam, and a paracetamol level at the appropriate interval with treatment per the poisoning protocol. [4]
• Place her in a safe, ligature-aware, low-stimulus room at an observation level matched to the risk. [4]
• Conduct the structured risk assessment: method, intent, expectation of death, planning, access to means, precipitant, prior history, substance use, abuse and bullying screen; mental state examination for hopelessness and active intent; and a validated brief screen (ASQ), supported where available by CASSY. [1] [2]
• Take collateral from the mother on the baseline, the recent change, and whether this is a departure; weigh protective factors. [7]
• Synthesise a risk stratum (low, moderate, high) from the whole assessment, not a single tool result. [1] [7]

Station B — Intoxication, capacity and the safety-net

Setup: The same girl re-presents (or a second young person presents) intoxicated and unable to give a consistent history; once sober she refuses admission. [4] [7]

Expected actions:

• Treat the medical consequences — glucose, co-ingestion, airway — and recognise that an intoxicated young person cannot be fully risk-assessed, so observe in a safe place and reassess as she sobers. [4]
• Exclude an organic or toxicological driver including delirium. [4] [7]
• Assess capacity formally once sober — decision-specific and time-specific — and, where capacity is present but risk is high and unmanageable, apply the local mental-health statute for involuntary assessment or treatment rather than relying on parental consent alone. [7]
• Build a safety plan with means-restriction counselling, give a crisis number, and confirm a follow-up contact within 24 to 72 hours. [6] [5]
• Recognise psychiatric boarding as a system failure if no bed is available and escalate actively while maintaining the observation level and the safety plan. [7] [5]

Marking anchors

Clear pass: performs the rapid medical screen and excludes the organic driver; demonstrates a structured risk assessment with a named validated tool; takes collateral; synthesises a risk stratum from the whole assessment; matches the disposition to the stratum with the least-restrictive principle; builds a safety plan with means restriction and a confirmed 24 to 72 hour follow-up; manages intoxication by deferring the definitive assessment and reassessing when sober; assesses capacity formally and applies the correct statutory principle for involuntary care. [1] [7] [5] Borderline: good engagement but the risk synthesis is incomplete, or means restriction or follow-up is mentioned but not made concrete, or capacity is discussed without the statutory principle. Fail: discharges a high-risk young person without a safety plan or follow-up; relies on a single screen result; omits the organic/toxicological exclusion; fails to reassess the intoxicated young person when sober; or applies a fixed age threshold for capacity. [4] [6] [3]

Debrief pearls

• Risk drives the level of care; acuity and risk are independent and assessed every time. [1] [3]
• No young person leaves without a safety plan, means restriction and a confirmed follow-up. [6] [5]
• Intoxication invalidates a definitive assessment — observe and reassess when sober. [4] [7]
• Capacity is decision- and time-specific; involuntary care is governed by local mental-health statute. [7] [5]