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emergency medical system; training; prehospital"> <meta name="citation_pdf_url" content="https://www.cambridge.org/core/services/aop-cambridge-core/content/view/17900D5E02942E7EFF46C8044C7A121C/S1935789324001824a.pdf/div-class-title-management-of-psychiatric-emergencies-and-associated-comfort-among-ems-physicians-in-lombardy-italy-a-cross-sectional-study-div.pdf"> <meta name="citation_reference" content="citation_title=Communication skills training for mental health professionals working with people with severe mental illness; citation_author=Papageorgiou, A; citation_author=Loke, YK; citation_author=Fromage, M.; citation_publication_date=2017; citation_journal_title=Cochrane Database Syst Rev.; citation_volume=6"> <meta name="citation_reference" content="7. Trattamenti Sanitari Obbligatori e Accertamenti Sanitari Obbligatori: Documento Regionale d’Indirizzo per L’esecuzione. Accessed July 26, 2023. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjQoMOUt7GAAxUDtqQKHQFeDMAQFnoECBIQAQ&url=http%3A%2F%2Fnormativasan.servizirl.it%2Fport%2FGetNormativaFile%3FfileName%3D13940_procedure_ASO_TSO.pdf&usg=AOvVaw2iUup9SpmlpX99ziHHEmQo&opi=89978449."> <meta name="citation_reference" content="citation_title=Emergency psychiatric consultations during and after the COVID-19 lockdown in Italy. A multicentre study; citation_author=Balestrieri, M; citation_author=Rucci, P; citation_author=Amendola, D; citation_publication_date=2021; citation_journal_title=Front Psychiatry.; citation_volume=12; citation_firstpage=697058.; citation_doi=10.3389/fpsyt.2021.697058"> <meta name="citation_reference" content="citation_title=Delphi methodology in health care research: How to decide its appropriateness; citation_author=Nasa, P; citation_author=Jain, R; citation_author=Juneja, D.; citation_publication_date=2021; citation_journal_title=World J Methodol.; citation_volume=11; citation_firstpage=116; citation_lastpage=129; citation_doi=10.5662/wjm.v11.i4.116"> <meta name="citation_reference" content="citation_title=The management of psychiatric emergencies; citation_author=Mavrogiorgou, P; citation_author=Brüne, M; citation_author=Juckel, G.; citation_publication_date=2011; citation_journal_title=Dtsch Arztebl Int.; citation_volume=108; citation_firstpage=222; citation_lastpage=230"> <meta name="citation_reference" content="citation_title=The implications of mental health call outs on paramedic practice. Dep Paramed Soc Health Sci; citation_author=Roberts, L.; citation_publication_date=2007"> <meta name="citation_reference" content="citation_title=Psychosocial work stress and occupational stressors in emergency medical services; citation_author=Bardhan, R; citation_author=Traci Byrd, T.; citation_publication_date=2023; citation_journal_title=Healthcare (Basel).; citation_volume=11; citation_firstpage=976; citation_doi=10.3390/healthcare11070976"> <meta name="citation_reference" content="citation_title=Response rates of online surveys in published research: a meta-analysis; citation_author=Wu, MJ; citation_author=Zhao, K; citation_author=Fils-Aime, F.; citation_publication_date=2022; citation_journal_title=Comp Hum Behav Rep.; citation_volume=7"> <meta name="citation_reference" content="citation_title=The global evolution of mental health problems during the COVID-19 pandemic: a systematic review and metaanalysis of longitudinal studies; citation_author=Cénat, JM; citation_author=Moshirian Farahi, SMM; citation_author=Dalexis, RD; citation_publication_date=2022; citation_journal_title=J Affect Disord.; citation_volume=315; citation_firstpage=70; citation_lastpage=95; citation_doi=10.1016/j.jad.2022.07.011"> <meta name="citation_reference" content="citation_title=The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public—a systematic review and meta-analysis; citation_author=Luo, M; citation_author=Guo, L; citation_author=Yu, M; citation_publication_date=2020; citation_journal_title=Psychiatry Res.; citation_volume=291; citation_firstpage=113190; citation_doi=10.1016/j.psychres.2020.113190"> <meta name="citation_reference" content="citation_title=Crisis intervention for people with severe mental illnesses; citation_author=Murphy, SM; citation_author=Irving, CB; citation_author=Adams, CE; citation_publication_date=2015; citation_journal_title=Cochrane Database Syst Rev.; citation_volume=3"> <meta name="citation_reference" content="citation_title=Navigating into the unknown: exploring the experience of exposure to prehospital emergency stressors: a sequential explanatory mixed-methods; citation_author=Afshari, A; citation_author=Torabi, M; citation_author=Navkhasi, S; citation_publication_date=2023; citation_journal_title=BMC Emerg Med.; citation_volume=23; citation_firstpage=136; citation_doi=10.1186/s12873-023-00906-7"> <meta name="citation_reference" content="citation_title=Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies; citation_author=Diamond, IR; citation_author=Grant, RC; citation_author=Feldman, BM; citation_publication_date=2014; citation_journal_title=Clin Epidemiol.; citation_volume=67; citation_firstpage=401; citation_lastpage=409; citation_doi=10.1016/j.jclinepi.2013.12.002"> <meta name="citation_reference" content="12. World Health Organization. Mental disorders. 2022. Accessed June 13, 2023. https://www.who.int/news-room/fact-sheets/detail/mental-disorders."> <meta name="citation_reference" content="citation_title=Mental health assessments in paramedic practice: a warrant for research and inquiry into accounts of paramedic clinical judgment and decision-making; citation_author=Shaban, R.; citation_publication_date=2004; citation_journal_title=J Emerg Prim Health Care.; citation_volume=2; citation_firstpage=1; citation_lastpage=8"> <meta name="citation_reference" content="citation_title=Assessing the knowledge of emergency medical care practitioners in the Free State, South Africa, on aspects of pre-hospital management of psychiatric emergencies; citation_author=Mothibi, JM; citation_author=Adefuye, AO; citation_publication_date=2019; citation_journal_title=Pan Afr Med J.; citation_volume=33; citation_firstpage=132; citation_doi=10.11604/pamj.2019.33.132.18426"> <meta name="citation_reference" content="citation_title=Mental health in Italy after two years of COVID-19 from the perspective of 1281 Italian physicians: looking back to plan forward; citation_author=Cuomo, A; citation_author=Amore, M; citation_author=Arezzo, MF; citation_publication_date=2022; citation_journal_title=Ann Gen Psychiatry.; citation_volume=21; citation_firstpage=30; citation_doi=10.1186/s12991-022-00410-5"> <meta name="citation_reference" content="citation_title=Psychiatric emergencies in preclinical emergency service; incidence, treatment and evaluation by emergency physicians and staff; citation_author=Pajonk, FG; citation_author=Bartels, HH; citation_author=Biberthaler, P; citation_publication_date=2001; citation_journal_title=Nervenarzt.; citation_volume=72; citation_firstpage=685; citation_lastpage=692; citation_doi=10.1007/s001150170047"> <meta name="citation_abstract" content="ObjectivesThe aims of this study were to explore the knowledge of EMS physicians (EMSPs) on the legal aspects related to the management of prehospital psychiatric emergencies, assess their degree of comfort, and measure their perceived communication skills.MethodsA survey was distributed to the 376 EMSPs working in the prehospital setting in Lombardy, Italy. Knowledge of medico-legal aspects was measured through multiple-choice questions; the Comfort Score (CS) and perceived Communication Skills Score (CSS) were calculated using Likert Scale questions. CS ranged from 11 points (lowest) to 44 (highest); CSS ranged from 8 points (lowest) to 32 (highest).ResultsA total of 272 EMSPs answered the survey (RR= 72.3%); 45.2% were women. Mean age was 45.76 years (SD 8.8). Mean percentage of correct knowledge test answers was 52.4 (SD 12.3); 81.3% believed to have little knowledge of the Italian legislation regarding this topic. Mean CS was 29.3 (SD 5.5); mean CSS was 19.1 (SD 3.9). A higher percentage of correct answers in the knowledge test was associated with lower CS (P = 0.019). Higher self-appraised knowledge of the Italian legislation was associated with higher CS (P &lt; 0.001) and higher CSS (P &lt; 0.001).ConclusionsThese findings should prompt policy makers to ensure proper training and support for EMSPs in the matter of prehospital psychiatric emergency management."> <meta name="citation_doi" content="10.1017/dmp.2024.182"> <link rel="alternate" href="/core/journals/disaster-medicine-and-public-health-preparedness/article/management-of-psychiatric-emergencies-and-associated-comfort-among-ems-physicians-in-lombardy-italy-a-crosssectional-study/17900D5E02942E7EFF46C8044C7A121C" hreflang="en" /> <link rel="icon" href="/core/cambridge-core/public/images/favicon.ico" type="image/x-icon"/> <link rel="shortcut icon" href="/core/cambridge-core/public/images/favicon.ico" type="image/x-icon"/> <link href='//fonts.googleapis.com/css?family=Noto+Sans:400,700,400italic,700italic' rel='stylesheet' type='text/css'>  <link rel="stylesheet" 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data-v-3692cf84><span data-v-63dfaf6e>Disaster Medicine and Public Health Preparedness</span> </a></li><li class="page-breadcrumbs__item" data-v-3692cf84><span aria-hidden="true" class="breadcrumbs-wrapper__arrow" data-v-3692cf84>></span><a href="/core/journals/disaster-medicine-and-public-health-preparedness/volume/B4BDDE64E8E1C7D85A7C176762D9E977" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-3692cf84><span data-v-63dfaf6e>Volume 18</span> </a></li><li class="page-breadcrumbs__item" data-v-3692cf84><span aria-hidden="true" class="breadcrumbs-wrapper__arrow" data-v-3692cf84>></span><span data-v-3692cf84>Management Of Psychiatric Emergencies and Associated...</span></li></ul></div></div> <div class="language" data-v-3692cf84><ul class="language-switch" data-v-6b1118dd data-v-3692cf84><li aria-label="English" data-v-6b1118dd><span class="language-option current divider" data-v-6b1118dd>English</span></li><li aria-label="Français" data-v-6b1118dd><span 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id="toc-list-wrapper" class="table-of-content__wrapper"><ul id="toc-list" class="list"><li class="list__item"><a href="#sec0" class="list__item__link"><span class="toc-title">Abstract</span></a></li> <li class="list__item"><a href="#sec1" class="list__item__link"> <span><div class="toc-title">Objectives</div></span></a></li><li class="list__item"><a href="#sec2" class="list__item__link"> <span><div class="toc-title">Methods</div></span></a></li><li class="list__item"><a href="#sec3" class="list__item__link"> <span><div class="toc-title">Results</div></span></a></li><li class="list__item"><a href="#sec4" class="list__item__link"> <span><div class="toc-title">Conclusions</div></span></a></li><li class="list__item"><a href="#sec5" class="list__item__link"> <span><div class="toc-title">Methods</div></span></a></li><li class="list__item"><a href="#sec11" class="list__item__link"> <span><div class="toc-title">Results</div></span></a></li><li class="list__item"><a href="#sec16" class="list__item__link"> <span><div class="toc-title">Multivariate Analyses</div></span></a></li><li class="list__item"><a href="#sec17" class="list__item__link"> <span><div class="toc-title">Limitations</div></span></a></li><li class="list__item"><a href="#sec18" class="list__item__link"> <span><div class="toc-title">Discussion</div></span></a></li><li class="list__item"><a href="#sec19" class="list__item__link"> <span><div class="toc-title">Conclusions</div></span></a></li><li class="list__item"><a href="#sec20" class="list__item__link"> <span><div class="toc-title">Author contribution</div></span></a></li><li class="list__item"><a href="#sec21" class="list__item__link"> <span><div class="toc-title">Funding</div></span></a></li><li class="list__item"><a href="#sec22" class="list__item__link"> <span><div class="toc-title">Competing interest</div></span></a></li>  <li class="list__item"><a href="#references-list" class="list__item__link"><span class="toc-title">References</span></a></li></ul></div></div></div> <div class="column__main" data-v-01274b1d><div class="row" data-v-01274b1d><div class="column__main__left" data-v-01274b1d><div id="maincontent" class="col" data-v-862424e6 data-v-01274b1d> <hgroup data-v-862424e6><h1 data-v-862424e6>Management Of Psychiatric Emergencies and Associated Comfort Among EMS Physicians in Lombardy, Italy: A Cross-Sectional Study</h1> </hgroup>     <div class="row published-date" data-v-862424e6><p data-v-862424e6> Published online by Cambridge University Press: <strong data-v-862424e6>13 November 2024</strong></p></div>   <div class="contributors-details" data-v-99f6eb26 data-v-862424e6><div class="row contributors" data-v-99f6eb26><div class="col" data-v-99f6eb26><div class="row contributor-type" data-v-792406ce data-v-99f6eb26> <div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Alba%20Ripoll-Gallardo&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Alba Ripoll-Gallardo</span> </a> <a target="_blank" href="https://orcid.org/0000-0003-4719-7333" data-test-orcid="Alba Ripoll-Gallardo" class="app-link contributor-type__contributor__orcid app-link__icon app-link--" data-v-63dfaf6e data-v-792406ce><img src="data:image/svg+xml;base64,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" alt="Open the ORCID record for Alba Ripoll-Gallardo" class="app-icon icon orcid" data-v-d2c09870 data-v-63dfaf6e> <span class="sr-only" data-v-63dfaf6e>[Opens in a new window]</span></a> <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Elisa%20Scarpolini&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Elisa Scarpolini</span> </a>  <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Giacomo%20Colzani&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Giacomo Colzani</span> </a>  <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Roberto%20Biella&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Roberto Biella</span> </a>  <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Ilaria%20Offredi&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Ilaria Offredi</span> </a>  <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Roberto%20Di%20Silvestre&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Roberto Di Silvestre</span> </a>  <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Claudia%20Giannotti&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Claudia Giannotti</span> </a>  <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Giuseppe%20Maria%20Sechi&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Giuseppe Maria Sechi</span> </a>  <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Roberto%20Fumagalli&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Roberto Fumagalli</span> </a>  <span data-v-792406ce> and</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Rita%20E%20Fioravanzo&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Rita E Fioravanzo</span> </a>  <span data-v-792406ce></span></div> <a href="#" class="app-link app-link__text-icon app-link--secondary reverse" data-v-63dfaf6e data-v-792406ce><img src="data:image/svg+xml;base64,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" alt="" class="app-icon icon arrow-down" data-v-d2c09870 data-v-63dfaf6e><span class="text" data-v-63dfaf6e>...Show all authors </span> </a></div> </div> <div class="col-2 collapse-link" data-v-99f6eb26><a href="#authors-details" data-toggle="collapse" aria-expanded="false" aria-controls="authors-details" class="app-link collapsed app-link__text-icon app-link--secondary reverse" data-v-63dfaf6e data-v-99f6eb26><img src="data:image/svg+xml;base64,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" alt="" class="app-icon icon arrow-down" data-v-d2c09870 data-v-63dfaf6e><span class="text" data-v-63dfaf6e>Show author details </span> </a></div></div> <hr aria-hidden="true" class="separator default" data-v-7036083a data-v-99f6eb26> <dl id="authors-details" class="authors-details collapse" data-v-2edb8da6 data-v-99f6eb26><div data-test-author="Alba Ripoll-Gallardo" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Alba Ripoll-Gallardo*</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>SSD AAT Milano, Agenzia Regionale Emergenza Urgenza (AREU), Dipartimento di Emergenza e Accettazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy</span> </span></div></dd></div><div data-test-author="Elisa Scarpolini" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Elisa Scarpolini</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>SSD AAT Milano, Agenzia Regionale Emergenza Urgenza (AREU), Dipartimento di Emergenza e Accettazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy</span> </span></div></dd></div><div data-test-author="Giacomo Colzani" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Giacomo Colzani</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>SSD AAT Milano, Agenzia Regionale Emergenza Urgenza (AREU), Dipartimento di Emergenza e Accettazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy</span> </span></div></dd></div><div data-test-author="Roberto Biella" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Roberto Biella</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Azienda Regionale Emergenza Urgenza (AREU) Lombardia, Milano, Italy</span> </span></div></dd></div><div data-test-author="Ilaria Offredi" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Ilaria Offredi</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Azienda Regionale Emergenza Urgenza (AREU) Lombardia, Milano, Italy</span> </span></div></dd></div><div data-test-author="Roberto Di Silvestre" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Roberto Di Silvestre</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Azienda Regionale Emergenza Urgenza (AREU) Lombardia, Milano, Italy</span> </span></div></dd></div><div data-test-author="Claudia Giannotti" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Claudia Giannotti</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>SSD AAT Milano, Agenzia Regionale Emergenza Urgenza (AREU), Dipartimento di Emergenza e Accettazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy</span> </span></div></dd></div><div data-test-author="Giuseppe Maria Sechi" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Giuseppe Maria Sechi</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Azienda Regionale Emergenza Urgenza (AREU) Lombardia, Milano, Italy</span> </span></div></dd></div><div data-test-author="Roberto Fumagalli" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Roberto Fumagalli</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy</span> </span><span data-v-2edb8da6><span data-v-2edb8da6>Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy</span> </span></div></dd></div><div data-test-author="Rita E Fioravanzo" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Rita E Fioravanzo</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Azienda Regionale Emergenza Urgenza (AREU) Lombardia, Milano, Italy</span> </span></div></dd></div><div data-test-author="Riccardo Stucchi" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Riccardo Stucchi</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>SSD AAT Milano, Agenzia Regionale Emergenza Urgenza (AREU), Dipartimento di Emergenza e Accettazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy</span> </span></div></dd></div> <div class="row" data-v-2edb8da6><dt class="col-sm-2 col-12 title" data-v-2edb8da6> * </dt> <dd class="col content" data-v-2edb8da6><div class="row" data-v-2edb8da6><div class="d-sm-flex d-inline flex-sm-1 flex-sm-wrap" data-v-2edb8da6><div class="d-inline" data-v-2edb8da6><span data-v-2edb8da6><div class="corresp"><span class="bold">Corresponding author:</span> Alba Ripoll Gallardo; Email: <a href="mailto:a.ripoll@areu.lombardia.it">a.ripoll@areu.lombardia.it</a></div></span></div></div></div></dd></div> <hr aria-hidden="true" class="separator default" data-v-7036083a data-v-2edb8da6></dl></div></div> <div id="app-tabs" class="tabs" data-v-1d90c6ce data-v-01274b1d><div id="app-tabs-wrapper" class="tabs__wrapper" data-v-1d90c6ce><div role="navigation" aria-label="tab navigation" class="container" data-v-1d90c6ce><a data-toggle="collapse" href="#appTabs" role="button" 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<span>Methods</span></a></li><li class="list__item"><a href="#sec11" class="list__item__link"> <span>Results</span></a></li><li class="list__item"><a href="#sec16" class="list__item__link"> <span>Multivariate Analyses</span></a></li><li class="list__item"><a href="#sec17" class="list__item__link"> <span>Limitations</span></a></li><li class="list__item"><a href="#sec18" class="list__item__link"> <span>Discussion</span></a></li><li class="list__item"><a href="#sec19" class="list__item__link"> <span>Conclusions</span></a></li><li class="list__item"><a href="#sec20" class="list__item__link"> <span>Author contribution</span></a></li><li class="list__item"><a href="#sec21" class="list__item__link"> <span>Funding</span></a></li><li class="list__item"><a href="#sec22" class="list__item__link"> <span>Competing interest</span></a></li>  <li class="list__item"><a href="#references-list" class="list__item__link"><span class="toc-title">References</span></a></li></ul></div> <div class="action-bar" 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target="_blank" href="https://s100.copyright.com/AppDispatchServlet?publisherName=CUP&publication=DMP&title=Management%20Of%20Psychiatric%20Emergencies%20and%20Associated%20Comfort%20Among%20EMS%20Physicians%20in%20Lombardy%2C%20Italy%3A%20A%20Cross-Sectional%20Study&publicationDate=13%20November%202024&author=Alba%20Ripoll-Gallardo%2C%20Elisa%20Scarpolini%2C%20Giacomo%20Colzani%2C%20Roberto%20Biella%2C%20Ilaria%20Offredi%2C%20Roberto%20Di%20Silvestre%2C%20Claudia%20Giannotti%2C%20Giuseppe%20Maria%20Sechi%2C%20Roberto%20Fumagalli%2C%20Rita%20E%20Fioravanzo%2C%20Riccardo%20Stucchi©right=%C2%A9%20The%20Author(s)%2C%202024.%20Published%20by%20Cambridge%20University%20Press%20on%20behalf%20of%20Society%20for%20Disaster%20Medicine%20and%20Public%20Health%2C%20Inc&contentID=10.1017%2Fdmp.2024.182&startPage=&endPage=&orderBeanReset=True&volumeNum=18&issueNum=&oa=" data-test-id="buttonRightLink" class="app-link rights-link d-print-none app-link__text-icon app-link--accent" data-v-63dfaf6e data-v-92ee52a2 data-v-43a4d572><img src="/core/page-component/img/rights-icon.d4a677c.svg" alt="" class="app-icon icon rights" data-v-d2c09870 data-v-63dfaf6e><span class="text" data-v-63dfaf6e>Rights & Permissions </span> <span class="sr-only" data-v-63dfaf6e>[Opens in a new window]</span></a></div> <hr aria-hidden="true" class="separator default" data-v-7036083a></div> <div class="share-modal-overlay" style="display:none;" data-v-43a4d572></div> <div data-spy="scroll" data-target="#toc" class="scrollspy-content" data-v-43a4d572> <div id="sec0" class="col article-abstract sec" data-v-2fa8b348 data-v-43a4d572><div class="abstract-text-container" data-v-2fa8b348><div lang="en"><h2>Abstract</h2>  <div class="abstract-content"><div class="abstract" data-abstract-type="normal"><div class="sec"><span class="bold">Objectives</span><p>The aims of this study were to explore the knowledge of EMS physicians (EMSPs) on the legal aspects related to the management of prehospital psychiatric emergencies, assess their degree of comfort, and measure their perceived communication skills.</p></div><div class="sec"><span class="bold">Methods</span><p>A survey was distributed to the 376 EMSPs working in the prehospital setting in Lombardy, Italy. Knowledge of medico-legal aspects was measured through multiple-choice questions; the Comfort Score (CS) and perceived Communication Skills Score (CSS) were calculated using Likert Scale questions. CS ranged from 11 points (lowest) to 44 (highest); CSS ranged from 8 points (lowest) to 32 (highest).</p></div><div class="sec"><span class="bold">Results</span><p>A total of 272 EMSPs answered the survey (RR= 72.3%); 45.2% were women. Mean age was 45.76 years (SD 8.8). Mean percentage of correct knowledge test answers was 52.4 (SD 12.3); 81.3% believed to have little knowledge of the Italian legislation regarding this topic. Mean CS was 29.3 (SD 5.5); mean CSS was 19.1 (SD 3.9). A higher percentage of correct answers in the knowledge test was associated with lower CS <span class="italic">(P =</span> 0.019). Higher self-appraised knowledge of the Italian legislation was associated with higher CS <span class="italic">(P < 0.</span>001) and higher CSS <span class="italic">(P <</span> 0.001).</p></div><div class="sec"><span class="bold">Conclusions</span><p>These findings should prompt policy makers to ensure proper training and support for EMSPs in the matter of prehospital psychiatric emergency management.</p></div></div></div> <hr aria-hidden="true" class="abstract-divider separator default" data-v-7036083a></div></div>   </div>  <div class="keywords" data-v-86c27100 data-v-43a4d572><h2 data-v-86c27100>Keywords</h2> <div class="row keywords__pills" data-v-86c27100><a href="/core/search?filters[keywords]=psychiatry" data-v-f0b31360 data-v-86c27100><span data-v-f0b31360 data-v-86c27100>psychiatry</span></a><a href="/core/search?filters[keywords]=emergency medical system" data-v-f0b31360 data-v-86c27100><span data-v-f0b31360 data-v-86c27100>emergency medical system</span></a><a href="/core/search?filters[keywords]=training" data-v-f0b31360 data-v-86c27100><span data-v-f0b31360 data-v-86c27100>training</span></a><a href="/core/search?filters[keywords]=prehospital" data-v-f0b31360 data-v-86c27100><span data-v-f0b31360 data-v-86c27100>prehospital</span></a></div> <hr aria-hidden="true" class="separator default" data-v-7036083a data-v-86c27100></div>  <dl class="article-details" data-v-6e32a161 data-v-43a4d572><div class="row" data-v-6e32a161><dt class="col-12 col-sm-3 col-md-2_5 title" data-v-6e32a161> Type </dt> <dd class="col content" data-v-6e32a161>Original Research</dd></div> <div class="row" data-v-6e32a161><dt class="col-12 col-sm-3 col-md-2_5 title" data-v-6e32a161> Information </dt> <dd class="col content" data-v-6e32a161><div class="content__journal" data-v-6e32a161><a href="/core/journals/disaster-medicine-and-public-health-preparedness" class="app-link app-link__text app-link--underlined" data-v-63dfaf6e data-v-6e32a161><span class="text" data-v-63dfaf6e>Disaster Medicine and Public Health Preparedness </span> </a> <span data-v-6e32a161> , <a href="/core/journals/disaster-medicine-and-public-health-preparedness/volume/B4BDDE64E8E1C7D85A7C176762D9E977" class="app-link app-link__text app-link--underlined" data-v-63dfaf6e data-v-6e32a161><span class="text" data-v-63dfaf6e>Volume 18 </span> </a></span>  <span data-v-6e32a161>, 2024</span>   <span data-v-6e32a161>, e267</span></div> <div class="doi-data" data-v-6e32a161><div data-v-6e32a161>DOI: <a target="_blank" href="https://doi.org/10.1017/dmp.2024.182" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-6e32a161><span class="text" data-v-63dfaf6e>https://doi.org/10.1017/dmp.2024.182 </span> <span class="sr-only" data-v-63dfaf6e>[Opens in a new window]</span></a></div> </div>  </dd></div>   <div class="row" data-v-6e32a161><dt class="col-12 col-sm-3 col-md-2_5 title" data-v-6e32a161> Copyright </dt> <dd class="col content" data-v-6e32a161><div data-v-6e32a161> © The Author(s), 2024. Published by Cambridge University Press on behalf of Society for Disaster Medicine and Public Health, Inc </div></dd></div></dl>  <div id="content-container" class="content-container" data-v-43a4d572><div class="content-box"><div class="article research-article NLM"> <div class="body"> <p class="p"> Following the COVID-19 outbreak, the entire health system in Lombardy was rapidly reorganized. Public mental health services were deemed a priority and, therefore, their continuation was ensured through the introduction of telemedicine and remote psychosocial interventions. However, mainly due to quarantines and social isolation, the pandemic was bound to carry negative effects on relapses or exacerbations of underneath psychiatric conditions.<a class="xref bibr" href="#r1"><span class="show-for-sr">Reference Cénat, Moshirian Farahi and Dalexis</span><sup class="sup">1</sup></a><sup class="sup">,</sup> <a class="xref bibr" href="#r2"><span class="show-for-sr">Reference Luo, Guo and Yu</span><sup class="sup">2</sup></a></p> <p class="p"> Balestrieri et al conducted a retrospective study on patients with acute psychiatric symptoms seeking consultation in hospital emergency departments during the lockdown and immediate post-lockdown.<a class="xref bibr" href="#r3"><span class="show-for-sr">Reference Balestrieri, Rucci and Amendola</span><sup class="sup">3</sup></a> Nine hospitals in Italy, 4 of which in Lombardy, were included. An increase of manic episodes and suicidality attempt/ideation was seen after the lockdown. Similarly, in the survey conducted by Cuomo et al.<a class="xref bibr" href="#r4"><span class="show-for-sr">Reference Cuomo, Amore and Arezzo</span><sup class="sup">4</sup></a> among 1281 Italian physicians 2 years after the first COVID-19 case in Italy, 81% affirmed that the number of people with mental illness seeking their service had increased during the pandemic. There was also the strong perception that the severity of pre-existing mental diseases had worsened during the pandemic and that an upward trend of stress-related conditions had to be expected.</p> <p class="p"> The management of psychiatric emergencies is complex and requires training in communication skills.<a class="xref bibr" href="#r5"><span class="show-for-sr">Reference Papageorgiou, Loke and Fromage</span><sup class="sup">5</sup></a> Besides, treatment should start as soon as the patient manifests the first symptom or sign of decompensation<a class="xref bibr" href="#r6"><span class="show-for-sr">Reference Murphy, Irving and Adams</span><sup class="sup">6</sup></a> to avoid harm, either to the patient or to others. Nevertheless, “who” must handle these cases and “how” they must be handled are subjected to national and local regulations and depend heavily on “where” the emergency occurs. Therefore, knowledge on the specific regulatory frameworks is paramount. In Lombardy, Emergency Medical Service physicians (EMSPs) will be in charge if the patient is deemed to be acutely in need of medical assistance outside health facilities.<a class="xref bibr" href="#r7"><sup class="sup">7</sup></a> The baseline psychosocial work stress in EMS is known to be high<a class="xref bibr" href="#r8"><span class="show-for-sr">Reference Afshari, Torabi and Navkhasi</span><sup class="sup">8</sup></a> and it has been further exacerbated by the COVID-19 pandemic.<a class="xref bibr" href="#r9"><span class="show-for-sr">Reference Bardhan and Traci Byrd</span><sup class="sup">9</sup></a> The aim of this study was to explore the knowledge among EMSPs on the legal aspects related to psychiatric disorders and gain an understanding of the degree of comfort and perceived communication skills of these professionals.</p> <div class="sec methods" data-magellan-destination="sec5" id="sec5"><h2 class="A"> Methods</h2> <p class="p"> This was a cross-sectional study based on an on-line survey.</p> <div class="sec" data-magellan-destination="sec6" id="sec6"><h3 class="B"> Population</h3> <p class="p"> All 378 EMSPs in Lombardy operating in the out-of-hospital setting were included in the study.</p> </div> <div class="sec" data-magellan-destination="sec7" id="sec7"><h3 class="B"> Development</h3> <p class="p"> In Italy, the prehospital system is run by the Regional Emergency Agency (AREU); a working group of AREU composed of 3 EMSPs, 2 psychologists, and 2 experts in legal medicine generated an itemized list of statements. A Delphi approach was adopted to seek agreement on the statements to be included in the survey through 3 cycles of iterative group discussions; these rounds involved all the aforementioned professionals plus an additional pool of 10 senior EMSPs.<a class="xref bibr" href="#r10"><span class="show-for-sr">Reference Nasa, Jain and Juneja</span><sup class="sup">10</sup></a> A senior EMSP was defined as having more than 15 years of experience in prehospital work. The level of adequacy of every item was rated as 1 = not adequate or 2 = adequate. To ensure validity, only items reaching at least 70% consensus were included in the questionnaire.<a class="xref bibr" href="#r11"><span class="show-for-sr">Reference Diamond, Grant and Feldman</span><sup class="sup">11</sup></a> The final product was a 54-item survey (available upon request).</p> </div> <div class="sec" data-magellan-destination="sec8" id="sec8"><h3 class="B"> Design</h3> <p class="p"> The final version of the survey included 5 sections.</p> <p class="p"> <em class="italic">Section A.</em> measured the knowledge in medico-legal aspects related to psychiatric emergencies. This section included 18 multiple-choice questions based on national and regional jurisprudence regarding, for example, the indications and timing for the execution of compulsory treatments. Results were reported as the mean of the 18 multiple-choice questions responses.</p> <p class="p"> <em class="italic">Section B.</em> measured EMSPs’ self-appraisal of knowledge of the Italian legislation on psychiatric emergencies (1 4-point Likert scale question). In addition, they were required to rate the quality of the training received so far in this specific topic and their fear of being harmed when facing these emergencies. This section included 9 4-point Likert scale questions.</p> <p class="p"> <em class="italic">Section C.</em> measured the Comfort Score (hereinafter CS) of EMSPs when dealing with psychiatric patients. This section included 11 4-point Likert scale questions, e.g., “To what extent are you anxious about managing a psychiatric emergency?” and “To what extent do you feel overwhelmed when managing a psychiatric emergency?” Each response added a maximum of 4 points and a minimum of 1. Therefore, CS ranged from 11 points (lowest CS) to 44 (highest CS).</p> <p class="p"> <em class="italic">Section D.</em> measured EMSPs perceived Communication Skills Score (hereinafter CSS). This section included 8 4-point Likert scale questions, e.g., “To what extent do you feel you have the necessary communication skills to handle aggressive patients?” and “To what extent do you feel you have the necessary communication skills to handle patients effected by paranoid disorders?” Each response added a maximum of 4 points and a minimum of 1. Therefore, CSS ranged from 8 points (lowest CSS) to 32 (highest CSS).</p> <p class="p"> <em class="italic">Section E, demographics.</em> Nine questions inquiring about gender, age, qualification, experience in the prehospital setting, and sector of practice (only prehospital or both prehospital and in-hospital).</p> <p class="p"> <em class="italic">Questionnaire distribution.</em> The questionnaire was distributed using the Google forms platform (Google, LLC; Mountain View, California USA). The email invitation included a short presentation of the study, a confidentiality disclosure statement and a link to the survey. Filling in the web-based survey implied agreement to participate in the study. Following the initial invitation, a total of 3 reminders followed. Each respondent was allowed to fill the survey once. The participation in the questionnaire was voluntary, anonymous, and independent. No financial incentives were offered.</p> <p class="p"> <em class="italic">Confidentiality.</em> Access to data stored in the internal server was only possible after entering the authors’ authentication credentials and not from public IP addresses. Prior to statistical analysis, all data were anonymized and reported in aggregate.</p> </div> <div class="sec" data-magellan-destination="sec9" id="sec9"><h3 class="B"> Statistical Analysis</h3> <p class="p"> Statistical analysis was carried out using SPSS (version 28). Prior to analyses, variable distribution was assessed using the Kolmogorof-Smirnov test, and accordingly, non-parametric analyses were then applied as adequate. After collection of the first 30 responses, the indices generated, namely, CS and CSS, were evaluated for reliability using the Cronbach’s Alpha test. In the overall sample, Cronbach’s alpha for CS and CSS were 0.838 and 0.870, respectively, indicating very good internal consistency. Association between continuous variables was assessed using the Spearman correlation. Mean differences between categories were assessed using the Mann-Whitney <em class="italic">U</em> test for dichotomous variables or the Kruskal-Wallis for more than 2 categories. Differences between categorical variables were assessed using the Chi-square test or Fisher’s exact test. Multivariate analysis was performed using a linear regression model to predict CS and CSS. In all statistical analyses, a <em class="italic">P</em> value of 0.05 was deemed significant.</p> </div> <div class="sec" data-magellan-destination="sec10" id="sec10"><h3 class="B"> Ethics Committee Approval</h3> <p class="p"> This study was approved by the Institutional Review Board Comitato Etico Territoriale Lombardia 3 (December 18, 2023; study n°3474).</p> </div> </div> <div class="sec results" data-magellan-destination="sec11" id="sec11"><h2 class="A"> Results</h2> <div class="sec" data-magellan-destination="sec12" id="sec12"><h3 class="B"> Population Characteristics</h3> <p class="p"> A total of 272 EMSPs answered the survey (RR = 72.3%); 45.2% were women. Mean age was 45.76 years (SD 8.8). A total of 223 were anesthetists (82%), 27 (9.9%) were ER doctors, and 22 (8.1%) had another medical background; 101 (37.1%) worked exclusively in the prehospital setting while 171 (62.9%) worked both at prehospital and in-hospital level. On average, participants had 13.8 years (SD 9.1) of experience working in the prehospital setting.</p> </div> <div class="sec" data-magellan-destination="sec13" id="sec13"><h3 class="B"> Legal knowledge of physicians</h3> <p class="p"> The mean percentage of correct answers in the legal knowledge test was 52.4% (SD 12.3) and the median was 50%; in terms of self-appraisal, 221 respondents (81.3%) did not feel knowledgeable enough ("nothing" or “a little”) on the provisions of the Italian legislation on this topic. A low percentage of correct answers in the legal knowledge test was not associated with a perceived poor knowledge of the Italian law <em class="italic">(R =</em> 0.009, <em class="italic">P</em> = 0.876). There was no association either between the percentage of correct answers and years of experience in the prehospital setting <em class="italic">(R =</em> 0.012, <em class="italic">P</em> = 0.844), setting of practice, (according to Mann-Whitney <em class="italic">U</em> test; <em class="italic">U</em> = 7893.00, <em class="italic">W</em> = 22 599.00, <em class="italic">P</em> = 0.232) or specialty (according to Kruskal-Wallis test; <em class="italic">H</em> = 3.151, <em class="italic">df</em> = 2, <em class="italic">P</em> = 0.207). Only 80 (29.4 %) and 90 (33.1%) were familiar with, respectively, the legal aspects concerning compulsory treatment and therapeutic necessity procedures. From a legal standpoint, 236 (86.8%) did not know what to do when a patient posed a danger to himself or others.</p> </div> <div class="sec" data-magellan-destination="sec14" id="sec14"><h3 class="B"> Physicians’ training</h3> <p class="p"> A total of 246 (90.5%) rated the training on the management of psychiatric emergencies received so far as <em class="italic">insufficient or scarce.</em> Similarly, 195 (71.7%) stated that these emergencies were not at all or only slightly receiving attention from political stakeholders. In addition, 139 (51.1%) were extremely or moderately afraid of being assaulted when dealing with a psychiatric patient with females being significantly more afraid than males (according to Mann-Whitney’s <em class="italic">U</em> test; <em class="italic">U</em> = 7790.00, <em class="italic">W</em> = 15 416.00, <em class="italic">P</em> = 0.02).</p> </div> <div class="sec" data-magellan-destination="sec15" id="sec15"><h3 class="B"> Comfort score and communication skills score</h3> <p class="p"> For illustration purposes, the results obtained for CS score were categorized into “very low” (11-17 points), “low” (18-24 points), “medium” (25-31 points), “high” (32-38 points), and “very high” (39- 44 points) (<a class="xref fig" href="#fig1">Figure 1</a>). Likewise, CSS score ranged from “very high” (28-32 points), “high” (23-27 points), “medium” (18-22 points), “low” (13-17 points), and “very low” (8-12 points) (<a class="xref fig" href="#fig2">Figure 2</a>). Mean CS among respondents was 29.3 (SD 5.5) while mean CSS was 19.1 (SD 3.9). Females showed lower CS (28.43±5.15SD) than males (30.02±5.77SD), according to Mann-Whitney’s <em class="italic">U</em> test (<em class="italic">U</em> = 7739.00, <em class="italic">W</em> = 15 365.50, <em class="italic">P</em> = 0.027). There was no statistical difference between females and males concerning CSS <em class="italic">(P =</em> 0.078). A higher percentage of correct answers in the legal knowledge test was associated with lower CS (<em class="italic">R =</em> 0.142, <em class="italic">P</em> = 0.019) but not with a higher CSS (<em class="italic">R</em> = -0.410, <em class="italic">P</em> = 0.502). Conversely, a higher perceived knowledge of the Italian legislation was associated with a higher CS (<em class="italic">R</em> = 0.295, <em class="italic">P</em> < 0.001) and higher CSS (<em class="italic">R</em> = 0.300, <em class="italic">P</em> < 0.001). Finally, there was no association between sector of practice and either CS or CSS (<em class="italic">P =</em> 0.200 and <em class="italic">P</em> = 0.663, respectively).</p><section><div class="fig" data-magellan-destination="fig1" id="fig1"> <div class="figure-thumb"><img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig1.png?pub-status=live" class="aop-lazy-load-image" width="1605" height="896" data-original-image="/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig1.png" data-zoomable="true"></div> <div class="caption"><p class="p"> </p><p class="p"><span class="label">Figure 1</span> Comfort Score (CS).</p> </div></div></section> <section><div class="fig" data-magellan-destination="fig2" id="fig2"> <div class="figure-thumb"><img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig2.png?pub-status=live" class="aop-lazy-load-image" width="1542" height="825" data-original-image="/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig2.png" data-zoomable="true"></div> <div class="caption"><p class="p"> </p><p class="p"><span class="label">Figure 2</span> Communication Skills Score (CSS).</p> </div></div></section> </div> </div> <div class="sec" data-magellan-destination="sec16" id="sec16"><h2 class="A"> Multivariate Analyses</h2> <p class="p"> In order to predict CS and CSS, 2 linear regression models were employed. Variables were entered into the models based on association in the univariate analysis and following negation of multi-collinearity (all variables met the model’s assumptions). The results of these analyses are provided in <a class="xref table" href="#tab1">Table 1</a>. The results show that for each of the dependent variables (CS and CSS), the strongest predictor is the other dependent variable.</p><div class="table-wrap" data-magellan-destination="tab1" id="tab1"> <div class="caption"> <p class="p"><span class="label">Table 1.</span> Results of linear regression model to predict (1) Comfort Score (CS) and (2) Communication Skills Score (CSS)</p> </div> <span> <div class="figure-thumb"><img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_tab1.png?pub-status=live" class="aop-lazy-load-image" width="2142" height="888" data-original-image="/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_tab1.png" data-zoomable="true"></div> </span> <div class="table-wrap-foot"> <p class="p"> Analysis was performed in Enter mode and included only variables associated with the dependent variable in the univariate analysis following negation of multi-collinearity (VIF values<2.5).</p> <p class="p"> Notes: Gender (Male = 0, Female = 1)</p> <div class="fn-group footnotes"> <div class="fn" data-magellan-destination="tab1fn1" id="tab1fn1"> <p class="p"><span class="label"><sup class="sup">****</sup></span> <em class="italic">P</em> value is significant at the 0.05 level (2-tailed)</p> </div> </div> <p class="p"> <em class="italic">P</em> value is significant at the 0.001 level (2-tailed) CS: Comfort Score CSS: Communication Skills Score.</p> </div> </div> </div> <div class="sec" data-magellan-destination="sec17" id="sec17"><h2 class="A"> Limitations</h2> <p class="p"> This study has several limitations; first, even though results showed that knowledge on legal aspects among EMSPs was low, this study was not designed to inquire about the cause at the root of this fact. Therefore, although it would be reasonable to think that poor training was, at least in part, responsible for these results, lack of interest among EMSPs in the medical treatment of this type of patient could be also a plausible explanation. Actual knowledge was included in the multivariate analyses while self-appraisal of knowledge was not. Therefore, whether perceived knowledge was a predictor of comfort or communication skills remains unknown.</p> <p class="p"> This survey was not designed to investigate whether EMSPs reckoned their duty to manage psychiatric emergencies to be ethical. In Italy, because EMSPs have usually a background in anesthesia and critical care, psychiatry clearly falls outside their medical background; this could arguably contribute to their lack of preparation and moderately low comfort. Finally, authors did not compare the CS caused by psychiatric emergencies to that caused by other regular EMS emergencies (e.g., cardiac arrest, trauma, etc.). Therefore, even though EMSPs should reasonably be more familiar with the latter, no assumptions can be made.</p> </div> <div class="sec discussion" data-magellan-destination="sec18" id="sec18"><h2 class="A"> Discussion</h2> <p class="p"> The burden of psychiatric emergencies continues to increase<a class="xref bibr" href="#r12"><sup class="sup">12</sup></a> with 60% of the cases in need of medical consultation occurring in non-psychiatric facilities.<a class="xref bibr" href="#r13"><span class="show-for-sr">Reference Mavrogiorgou, Brüne and Juckel</span><sup class="sup">13</sup></a> At the time of writing, this was the first manuscript inquiring about knowledge and feelings of EMS practitioners when managing these emergencies in Lombardy.</p> <p class="p"> Participation in this online survey was high compared to the mean response rate reported in literature.<a class="xref bibr" href="#r14"><span class="show-for-sr">Reference Wu, Zhao and Fils-Aime</span><sup class="sup">14</sup></a> This might be because psychiatric emergencies represent a relevant part of the total number of medical prehospital events while, at the same time, pose unique challenges for EMSPs.<a class="xref bibr" href="#r15"><span class="show-for-sr">Reference Shaban</span><sup class="sup">15</sup></a><sup class="sup">,</sup> <a class="xref bibr" href="#r16"><span class="show-for-sr">Reference Roberts</span><sup class="sup">16</sup></a> In Italy, the medical approach to psychiatric emergencies is subject to specific laws. When patients require immediate mental health treatment and access to the hospital does not occur on voluntary basis, compulsory treatment might be required in the absence of any outpatient treatment alternative.<a class="xref bibr" href="#r3"><span class="show-for-sr">Reference Balestrieri, Rucci and Amendola</span><sup class="sup">3</sup></a> In these cases, cooperation with the police department is mandatory and good knowledge of the legal and administrative procedures is also required to safeguard patient’s dignity and rights while protecting EMSPs professionalism.</p> <p class="p"> The present study highlighted that knowledge and self-appraisal of knowledge of the Italian legislation on the topic of psychiatric emergencies were low. This was in line with the results obtained by Mothibi et al. and Pajonk et al. in similar studies conducted in South Africa and Germany.<a class="xref bibr" href="#r17"><span class="show-for-sr">Reference Pajonk, Bartels and Biberthaler</span><sup class="sup">17</sup></a><sup class="sup">,</sup> <a class="xref bibr" href="#r18"><span class="show-for-sr">Reference Mothibi and Adefuye</span><sup class="sup">18</sup></a> Extremely worrisome was that most respondents didn’t know how to clinically address a dangerous patient according to the Italian law.<a class="xref bibr" href="#r7"><sup class="sup">7</sup></a> Interestingly, neither long experience doing prehospital emergency care nor practicing exclusively in the prehospital setting were associated with better performance in the knowledge test. At the current stage, the authors cannot give an explanation for these results. These data may support the complexity of these cases and also draw attention to the fact that correct management of psychiatric emergencies cannot rely only upon personal experience but must be supported by solid training.</p> <p class="p"> Italian Law establishes that every physician licensed to practice must be able to first, recognize and assess a patient in acute mental health decompensation and second, choose the safer approach according to his actual clinical condition and in full respect of his rights.<a class="xref bibr" href="#r7"><sup class="sup">7</sup></a> However, the vast majority of EMSPs admitted feeling unprepared. Aside of legal aspects, it’s important to remember that psychiatric disorders embrace a big variety of underlying clinical conditions e.g., anxiety, depression, bipolar disorder, substance abuse, and schizophrenia to name but a few. None of these clinical presentations are included in the regular training of EMS doctors in Italy. Without proper training including psychological, clinical, legal, and ethical aspects, the management of psychiatric emergences will continue to be heterogeneous and even harmful for patients and EMSPs.</p> <p class="p"> Interestingly, a cumulative percent of 59, 2% expressed a medium to a very low CS when asked to manage psychiatric patients. Considering that these professionals are required to treat life-threatening emergencies on daily basis (e.g., severe trauma, sudden cardiac arrest or acute respiratory failure), these results deserve special consideration. Psychiatric emergencies can, as such, be grouped into declared suicidal ideation or acute excitement with psychomotor agitation.<a class="xref bibr" href="#r13"><span class="show-for-sr">Reference Mavrogiorgou, Brüne and Juckel</span><sup class="sup">13</sup></a> Therefore, they seldom represent an actual life-threatening emergency unless the patient is actually on the brink of committing suicide. The fact that they lead to psychological stress could arguably be an alarming hint of the global unpreparedness of our target population. It’s also interesting to note that EMSPs who performed better in the legal knowledge test also manifested lower CS. A plausible explanation could be that these professionals were simply more aware of the difficulties entailed by these cases and thus, enhanced their preparedness on the topic. Nevertheless, this explanation should be made with caution, given that actual knowledge did not emerge as a significant predictor of neither CS nor CSS in the multivariate analysis.</p> <p class="p"> It is worth noting that most EMSPs weren’t confident with their communication skills. When dealing with acute psychiatric disorders, physicians must establish a personal approach with the patient and collect key information faster than in a regular medical interview. Apart from patients’ complaints, observing patients’ behavior and speaking to relatives or patient’s acquaintances to inquire about similar episodes in the past are important.<a class="xref bibr" href="#r13"><span class="show-for-sr">Reference Mavrogiorgou, Brüne and Juckel</span><sup class="sup">13</sup></a> Moreover, a respectful, rational, and empathetic attitude is a cornerstone in the management of psychiatric emergencies as it may determine the therapeutic measures that will follow next.<a class="xref bibr" href="#r13"><span class="show-for-sr">Reference Mavrogiorgou, Brüne and Juckel</span><sup class="sup">13</sup></a></p> <p class="p"> Finally, this study aimed to draw attention to the worryingly poor preparedness of EMS when it comes to psychiatric emergencies. Given that the EMS health care personnel in Lombardy is mainly medical and not paramedical, no published training programs seem to match the needs of our target population. Moreover, the challenges posed by acute psychiatric disorders and the specificities of the national and regional jurisprudence impose the development of a training program involving AREU, the police department, and municipalities. In addition, shared guidelines are urgently needed to ensure a good clinical approach and reduce the variability in operational practices.</p> </div> <div class="sec conclusions" data-magellan-destination="sec19" id="sec19"><h2 class="A"> Conclusions</h2> <p class="p"> Knowledge and perceived knowledge of Italian Law concerning psychiatric emergencies was low among EMSPs in Lombardy. There was no association between legal knowledge and work experience in the prehospital setting. The majority of respondents defined the training received on the management of these cases as insufficient and stated that these emergencies deserved more attention. Most doctors were afraid of being physically assaulted. Comfort and self- appraisal of communication skills were low across our target population. Higher legal knowledge was associated with lower comfort but not with a higher perception of communication skills. Higher perceived knowledge of the Italian legislation was associated with a higher comfort and higher perceived communication skills.</p> </div> </div> <div class="back"> <div class="ack"><h2 class="A"> Acknowledgments</h2> <p class="p"> The authors thank Enzo Griffone, Gianni Maggioni, Grazia Marziale, Marta Norelli, Michele Franchini, Gianluca Dilettoso, Riccardo Cusmà Piccione, Riccardo Maruzzo, Silvia Gennari, Barbara Porro, Alessandra Cozzi, Giovanni De Luca, Barbara Massasogni, Roberto Bertelè, Gaia Radici, Marco Malaffo, Andre Colombini, Elisabetta Samperisi, Chaira Trione, Valerio Bernardi, Elisa Ghezzi, Arianna Albuzzi, Giovanna Durante, Giacomo Ricca, Luigi Dolcino, Paola Plebani, Stefano Vanzini, Gianluca Donati, Matteo Vargiu, Davide La Leggia Davide, Orietta Mapelli, Lara Barbin, Matteo Giacovelli, Cristian Rampin, Franco Lorito, and Pelà Simone for their interest and priceless contribution to ensure the validity and reliabilty of this survey.</p> </div> <div class="sec" data-magellan-destination="sec20" id="sec20"><h2 class="A"> Author contribution</h2> <p class="p"> Ripoll-Gallardo A- Designed and directed the project. Wrote the first draft of the manuscript.</p> <p class="p"> Scarpolini E- Contributed to the design of the study. Performed the data collection. Approved the version to be published.</p> <p class="p"> Colzani G- Approved the version to be published.</p> <p class="p"> Biella R- Contributed to the design of the questionnaire. Approved the version to be published.</p> <p class="p"> Offredi I- Contributed to the design of the questionnaire. Approved the version to be published.</p> <p class="p"> Di Silvestre R- Contributed to the design of the questionnaire. Approved the version to be published.</p> <p class="p"> Giannotti C- Approved the version to be published.</p> <p class="p"> Sechi GM- Approved the version to be published.</p> <p class="p"> Fumagalli R- Approved the version to be published.</p> <p class="p"> Fioravanzo R- Approved the version to be published.</p> <p class="p"> Stucchi R- Approved the version to be published.</p> </div> <div class="sec funding-statement" data-magellan-destination="sec21" id="sec21"><h2 class="A"> Funding</h2> <p class="p"> None.</p> </div> <div class="sec coi-statement" data-magellan-destination="sec22" id="sec22"><h2 class="A"> Competing interest</h2> <p class="p"> None.</p> </div> </div> </div></div>   <hr aria-hidden="true" class="list-divider separator default" data-v-7036083a> <div id="references-list" class="circle-list"><h2>References</h2> <div id="r1" aria-flowto="reference-1-content reference-1-button" class="circle-list__item"> <div class="circle-list__item__indicator"><AppButton 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href=https://dx.doi.org/10.11604/pamj.2019.33.132.18426>CrossRef</a><a class='ref-link' target='_blank' aria-label='Google Scholar link for Assessing the knowledge of emergency medical care practitioners in the Free State, South Africa, on aspects of pre-hospital management of psychiatric emergencies' href=https://scholar.google.com/scholar_lookup?title=Assessing+the+knowledge+of+emergency+medical+care+practitioners+in+the+Free+State%2C+South+Africa%2C+on+aspects+of+pre-hospital+management+of+psychiatric+emergencies&author=Mothibi+JM&author=Adefuye+AO&publication+year=2019&journal=Pan+Afr+Med+J.&volume=33&doi=10.11604%2Fpamj.2019.33.132.18426>Google Scholar</a><a class='ref-link' target='_blank' aria-label='PubMed link for Assessing the knowledge of emergency medical care practitioners in the Free State, South Africa, on aspects of pre-hospital management of psychiatric emergencies' href=https://www.ncbi.nlm.nih.gov/pubmed/31558931>PubMed</a></div></div></div></div></div> </div></div>  <div id="figures-tab" class="figures tab-pane" data-v-241a4b23><div data-v-241a4b23><div class="figures__item" data-v-241a4b23><div class="figures__item__image-box" data-v-241a4b23><button class="figures__ref" data-v-241a4b23> View in content </button> <img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" alt="Figure 0" data-zoomable="true" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig1.png" data-enlarged-image="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig1.png" class="graphic" data-v-241a4b23></div> <div data-v-241a4b23><div class="caption" data-v-241a4b23><p data-v-241a4b23><span class="label" data-v-241a4b23>Figure 1</span> <span data-v-241a4b23><span class="p">Comfort Score (CS).</span></span></p></div> </div></div> <hr aria-hidden="true" class="separator dashed" data-v-7036083a data-v-241a4b23></div><div data-v-241a4b23><div class="figures__item" data-v-241a4b23><div class="figures__item__image-box" data-v-241a4b23><button class="figures__ref" data-v-241a4b23> View in content </button> <img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" alt="Figure 1" data-zoomable="true" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig2.png" data-enlarged-image="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig2.png" class="graphic" data-v-241a4b23></div> <div data-v-241a4b23><div class="caption" data-v-241a4b23><p data-v-241a4b23><span class="label" data-v-241a4b23>Figure 2</span> <span data-v-241a4b23><span class="p">Communication Skills Score (CSS).</span></span></p></div> </div></div> <hr aria-hidden="true" class="separator dashed" data-v-7036083a data-v-241a4b23></div><div data-v-241a4b23><div class="figures__item" data-v-241a4b23><div class="figures__item__image-box" data-v-241a4b23><button class="figures__ref" data-v-241a4b23> View in content </button> <img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" alt="Figure 2" data-zoomable="true" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary-alt:20241113045948-93397-mediumThumb-png-S1935789324001824_tab1.jpg" data-enlarged-image="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary-alt:20241113045948-12907-optimisedImage-png-S1935789324001824_tab1.jpg" class="graphic" data-v-241a4b23></div> <div data-v-241a4b23><div class="caption" data-v-241a4b23><p data-v-241a4b23><span class="label" data-v-241a4b23>Table 1.</span> <span data-v-241a4b23><span class="p">Results of linear regression model to predict (1) Comfort Score (CS) and (2) Communication Skills Score (CSS)</span></span></p></div> </div></div> </div></div>         <div id="metrics-tab" publication-date="13 November 2024" class="metrics tab-pane" data-v-c41a0c86><div class="app-loader" data-v-c41a0c86></div></div></div></div> </div> <div role="complementary" aria-label="related contents" class="column__main__right" data-v-01274b1d><div class="access-block row access-status" data-v-5fad35b8 data-v-01274b1d><span class="has-access" data-v-5fad35b8><img 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Ripoll-Gallardo",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Alba%20Ripoll-Gallardo&eventCode=SE-AU",orcidUrl:"https:\u002F\u002Forcid.org\u002F0000-0003-4719-7333"},{givenNames:"Elisa",surname:"Scarpolini",nameStyle:i,affiliations:[{text:j}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Elisa Scarpolini",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Elisa%20Scarpolini&eventCode=SE-AU",orcidUrl:e},{givenNames:"Giacomo",surname:"Colzani",nameStyle:i,affiliations:[{text:j}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Giacomo Colzani",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Giacomo%20Colzani&eventCode=SE-AU",orcidUrl:e},{givenNames:r,surname:"Biella",nameStyle:i,affiliations:[{text:k}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Roberto Biella",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Roberto%20Biella&eventCode=SE-AU",orcidUrl:e},{givenNames:"Ilaria",surname:"Offredi",nameStyle:i,affiliations:[{text:k}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Ilaria Offredi",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Ilaria%20Offredi&eventCode=SE-AU",orcidUrl:e},{givenNames:r,surname:"Di Silvestre",nameStyle:i,affiliations:[{text:k}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Roberto Di Silvestre",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Roberto%20Di%20Silvestre&eventCode=SE-AU",orcidUrl:e},{givenNames:"Claudia",surname:"Giannotti",nameStyle:i,affiliations:[{text:j}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Claudia Giannotti",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Claudia%20Giannotti&eventCode=SE-AU",orcidUrl:e},{givenNames:"Giuseppe Maria",surname:"Sechi",nameStyle:i,affiliations:[{text:k}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Giuseppe Maria Sechi",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Giuseppe%20Maria%20Sechi&eventCode=SE-AU",orcidUrl:e},{givenNames:r,surname:"Fumagalli",nameStyle:i,affiliations:[{text:"Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy"},{text:"Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy"}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Roberto Fumagalli",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Roberto%20Fumagalli&eventCode=SE-AU",orcidUrl:e},{givenNames:"Rita E",surname:"Fioravanzo",nameStyle:i,affiliations:[{text:k}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Rita E Fioravanzo",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Rita%20E%20Fioravanzo&eventCode=SE-AU",orcidUrl:e},{givenNames:"Riccardo",surname:"Stucchi",nameStyle:i,affiliations:[{text:j}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Riccardo Stucchi",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Riccardo%20Stucchi&eventCode=SE-AU",orcidUrl:e}]},translators:{contributors:[],label:"Translated by"}},collections:[],publishedDate:"13 November 2024",keywords:[{url:"\u002Fcore\u002Fsearch?filters[keywords]=psychiatry",name:"psychiatry"},{url:"\u002Fcore\u002Fsearch?filters[keywords]=emergency medical system",name:"emergency medical system"},{url:"\u002Fcore\u002Fsearch?filters[keywords]=training",name:"training"},{url:"\u002Fcore\u002Fsearch?filters[keywords]=prehospital",name:"prehospital"}],openPracticeBadges:[],doi:{url:"https:\u002F\u002Fdoi.org\u002F10.1017\u002Fdmp.2024.182",value:"10.1017\u002Fdmp.2024.182"},copyright:{statement:["© The Author(s), 2024. Published by Cambridge University Press on behalf of Society for Disaster Medicine and Public Health, Inc"],holder:["The Author(s)"],year:[2024]},creativeCommons:e,acceptedManuscript:a,type:"research-article",typeDescription:"Original Research",eNumber:"e267",resultTypes:[],commentsCount:s,topicsAndSubtopics:e},journal:{id:v,title:m,titleSlug:w,mnemonic:"DMP",titleHistory:[],isFirstView:a,journalSlug:w,isCompanion:a,parentCompanionJournalName:m,associatedParentCollection:e,paymentInfo:{prices:{"£":{price:26,sku:n,skuNew:l,currency:"£"},"€":{price:31,sku:n,skuNew:l,currency:"€"},US$:{price:36,sku:n,skuNew:l,currency:"US$"},AU$:{price:51,sku:n,skuNew:l,currency:"AU$"}}},url:x,firstViewUrl:"\u002Fcore\u002Fjournals\u002Fdisaster-medicine-and-public-health-preparedness\u002Ffirstview",coverUrl:"https:\u002F\u002Fstatic.cambridge.org\u002Fcovers\u002FDMP_0_0_0\u002Fdisaster-medicine-and-public-health-preparedness.jpg",submitMaterialsUrl:"\u002Fcore\u002Fjournals\u002Fdisaster-medicine-and-public-health-preparedness\u002Finformation\u002Fauthor-instructions\u002Fsubmitting-your-materials",hasHistory:a,latestTitle:m,latestId:v,hasPastTitle:a,volume:{id:"B4BDDE64E8E1C7D85A7C176762D9E977",number:y,title:z,publishedDate:"2024",printPublishTimestamp:1704067200000,url:A}},abstract:{textAbstracts:[{title:"Abstract",content:"\u003Cdiv class=\"abstract\" data-abstract-type=\"normal\"\u003E\u003Cdiv class=\"sec\"\u003E\u003Cspan class=\"bold\"\u003EObjectives\u003C\u002Fspan\u003E\u003Cp\u003EThe aims of this study were to explore the knowledge of EMS physicians (EMSPs) on the legal aspects related to the management of prehospital psychiatric emergencies, assess their degree of comfort, and measure their perceived communication skills.\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"sec\"\u003E\u003Cspan class=\"bold\"\u003EMethods\u003C\u002Fspan\u003E\u003Cp\u003EA survey was distributed to the 376 EMSPs working in the prehospital setting in Lombardy, Italy. Knowledge of medico-legal aspects was measured through multiple-choice questions; the Comfort Score (CS) and perceived Communication Skills Score (CSS) were calculated using Likert Scale questions. CS ranged from 11 points (lowest) to 44 (highest); CSS ranged from 8 points (lowest) to 32 (highest).\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"sec\"\u003E\u003Cspan class=\"bold\"\u003EResults\u003C\u002Fspan\u003E\u003Cp\u003EA total of 272 EMSPs answered the survey (RR= 72.3%); 45.2% were women. Mean age was 45.76 years (SD 8.8). Mean percentage of correct knowledge test answers was 52.4 (SD 12.3); 81.3% believed to have little knowledge of the Italian legislation regarding this topic. Mean CS was 29.3 (SD 5.5); mean CSS was 19.1 (SD 3.9). A higher percentage of correct answers in the knowledge test was associated with lower CS \u003Cspan class=\"italic\"\u003E(P =\u003C\u002Fspan\u003E 0.019). Higher self-appraised knowledge of the Italian legislation was associated with higher CS \u003Cspan class=\"italic\"\u003E(P < 0.\u003C\u002Fspan\u003E001) and higher CSS \u003Cspan class=\"italic\"\u003E(P <\u003C\u002Fspan\u003E 0.001).\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"sec\"\u003E\u003Cspan class=\"bold\"\u003EConclusions\u003C\u002Fspan\u003E\u003Cp\u003EThese findings should prompt policy makers to ensure proper training and support for EMSPs in the matter of prehospital psychiatric emergency management.\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E",lang:B}]},content:{html:"\u003Cdiv class=\"article research-article NLM\"\u003E\n\n\u003Cdiv class=\"body\"\u003E\n\u003Cp class=\"p\"\u003E Following the COVID-19 outbreak, the entire health system in Lombardy was rapidly reorganized. Public mental health services were deemed a priority and, therefore, their continuation was ensured through the introduction of telemedicine and remote psychosocial interventions. However, mainly due to quarantines and social isolation, the pandemic was bound to carry negative effects on relapses or exacerbations of underneath psychiatric conditions.\u003Ca class=\"xref bibr\" href=\"#r1\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Cénat, Moshirian Farahi and Dalexis\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E1\u003C\u002Fsup\u003E\u003C\u002Fa\u003E\u003Csup class=\"sup\"\u003E,\u003C\u002Fsup\u003E \u003Ca class=\"xref bibr\" href=\"#r2\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Luo, Guo and Yu\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E2\u003C\u002Fsup\u003E\u003C\u002Fa\u003E\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Balestrieri et al conducted a retrospective study on patients with acute psychiatric symptoms seeking consultation in hospital emergency departments during the lockdown and immediate post-lockdown.\u003Ca class=\"xref bibr\" href=\"#r3\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Balestrieri, Rucci and Amendola\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E3\u003C\u002Fsup\u003E\u003C\u002Fa\u003E Nine hospitals in Italy, 4 of which in Lombardy, were included. An increase of manic episodes and suicidality attempt\u002Fideation was seen after the lockdown. Similarly, in the survey conducted by Cuomo et al.\u003Ca class=\"xref bibr\" href=\"#r4\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Cuomo, Amore and Arezzo\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E4\u003C\u002Fsup\u003E\u003C\u002Fa\u003E among 1281 Italian physicians 2 years after the first COVID-19 case in Italy, 81% affirmed that the number of people with mental illness seeking their service had increased during the pandemic. There was also the strong perception that the severity of pre-existing mental diseases had worsened during the pandemic and that an upward trend of stress-related conditions had to be expected.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E The management of psychiatric emergencies is complex and requires training in communication skills.\u003Ca class=\"xref bibr\" href=\"#r5\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Papageorgiou, Loke and Fromage\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E5\u003C\u002Fsup\u003E\u003C\u002Fa\u003E Besides, treatment should start as soon as the patient manifests the first symptom or sign of decompensation\u003Ca class=\"xref bibr\" href=\"#r6\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Murphy, Irving and Adams\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E6\u003C\u002Fsup\u003E\u003C\u002Fa\u003E to avoid harm, either to the patient or to others. Nevertheless, “who” must handle these cases and “how” they must be handled are subjected to national and local regulations and depend heavily on “where” the emergency occurs. Therefore, knowledge on the specific regulatory frameworks is paramount. In Lombardy, Emergency Medical Service physicians (EMSPs) will be in charge if the patient is deemed to be acutely in need of medical assistance outside health facilities.\u003Ca class=\"xref bibr\" href=\"#r7\"\u003E\u003Csup class=\"sup\"\u003E7\u003C\u002Fsup\u003E\u003C\u002Fa\u003E The baseline psychosocial work stress in EMS is known to be high\u003Ca class=\"xref bibr\" href=\"#r8\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Afshari, Torabi and Navkhasi\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E8\u003C\u002Fsup\u003E\u003C\u002Fa\u003E and it has been further exacerbated by the COVID-19 pandemic.\u003Ca class=\"xref bibr\" href=\"#r9\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Bardhan and Traci Byrd\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E9\u003C\u002Fsup\u003E\u003C\u002Fa\u003E The aim of this study was to explore the knowledge among EMSPs on the legal aspects related to psychiatric disorders and gain an understanding of the degree of comfort and perceived communication skills of these professionals.\u003C\u002Fp\u003E\n\u003Cdiv class=\"sec methods\" data-magellan-destination=\"sec5\" id=\"sec5\"\u003E\u003Ch2 class=\"A\"\u003E Methods\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E This was a cross-sectional study based on an on-line survey.\u003C\u002Fp\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec6\" id=\"sec6\"\u003E\u003Ch3 class=\"B\"\u003E Population\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E All 378 EMSPs in Lombardy operating in the out-of-hospital setting were included in the study.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec7\" id=\"sec7\"\u003E\u003Ch3 class=\"B\"\u003E Development\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E In Italy, the prehospital system is run by the Regional Emergency Agency (AREU); a working group of AREU composed of 3 EMSPs, 2 psychologists, and 2 experts in legal medicine generated an itemized list of statements. A Delphi approach was adopted to seek agreement on the statements to be included in the survey through 3 cycles of iterative group discussions; these rounds involved all the aforementioned professionals plus an additional pool of 10 senior EMSPs.\u003Ca class=\"xref bibr\" href=\"#r10\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Nasa, Jain and Juneja\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E10\u003C\u002Fsup\u003E\u003C\u002Fa\u003E A senior EMSP was defined as having more than 15 years of experience in prehospital work. The level of adequacy of every item was rated as 1 = not adequate or 2 = adequate. To ensure validity, only items reaching at least 70% consensus were included in the questionnaire.\u003Ca class=\"xref bibr\" href=\"#r11\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Diamond, Grant and Feldman\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E11\u003C\u002Fsup\u003E\u003C\u002Fa\u003E The final product was a 54-item survey (available upon request).\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec8\" id=\"sec8\"\u003E\u003Ch3 class=\"B\"\u003E Design\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E The final version of the survey included 5 sections.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003Cem class=\"italic\"\u003ESection A.\u003C\u002Fem\u003E measured the knowledge in medico-legal aspects related to psychiatric emergencies. This section included 18 multiple-choice questions based on national and regional jurisprudence regarding, for example, the indications and timing for the execution of compulsory treatments. Results were reported as the mean of the 18 multiple-choice questions responses.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003Cem class=\"italic\"\u003ESection B.\u003C\u002Fem\u003E measured EMSPs’ self-appraisal of knowledge of the Italian legislation on psychiatric emergencies (1 4-point Likert scale question). In addition, they were required to rate the quality of the training received so far in this specific topic and their fear of being harmed when facing these emergencies. This section included 9 4-point Likert scale questions.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003Cem class=\"italic\"\u003ESection C.\u003C\u002Fem\u003E measured the Comfort Score (hereinafter CS) of EMSPs when dealing with psychiatric patients. This section included 11 4-point Likert scale questions, e.g., “To what extent are you anxious about managing a psychiatric emergency?” and “To what extent do you feel overwhelmed when managing a psychiatric emergency?” Each response added a maximum of 4 points and a minimum of 1. Therefore, CS ranged from 11 points (lowest CS) to 44 (highest CS).\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003Cem class=\"italic\"\u003ESection D.\u003C\u002Fem\u003E measured EMSPs perceived Communication Skills Score (hereinafter CSS). This section included 8 4-point Likert scale questions, e.g., “To what extent do you feel you have the necessary communication skills to handle aggressive patients?” and “To what extent do you feel you have the necessary communication skills to handle patients effected by paranoid disorders?” Each response added a maximum of 4 points and a minimum of 1. Therefore, CSS ranged from 8 points (lowest CSS) to 32 (highest CSS).\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003Cem class=\"italic\"\u003ESection E, demographics.\u003C\u002Fem\u003E Nine questions inquiring about gender, age, qualification, experience in the prehospital setting, and sector of practice (only prehospital or both prehospital and in-hospital).\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003Cem class=\"italic\"\u003EQuestionnaire distribution.\u003C\u002Fem\u003E The questionnaire was distributed using the Google forms platform (Google, LLC; Mountain View, California USA). The email invitation included a short presentation of the study, a confidentiality disclosure statement and a link to the survey. Filling in the web-based survey implied agreement to participate in the study. Following the initial invitation, a total of 3 reminders followed. Each respondent was allowed to fill the survey once. The participation in the questionnaire was voluntary, anonymous, and independent. No financial incentives were offered.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003Cem class=\"italic\"\u003EConfidentiality.\u003C\u002Fem\u003E Access to data stored in the internal server was only possible after entering the authors’ authentication credentials and not from public IP addresses. Prior to statistical analysis, all data were anonymized and reported in aggregate.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec9\" id=\"sec9\"\u003E\u003Ch3 class=\"B\"\u003E Statistical Analysis\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E Statistical analysis was carried out using SPSS (version 28). Prior to analyses, variable distribution was assessed using the Kolmogorof-Smirnov test, and accordingly, non-parametric analyses were then applied as adequate. After collection of the first 30 responses, the indices generated, namely, CS and CSS, were evaluated for reliability using the Cronbach’s Alpha test. In the overall sample, Cronbach’s alpha for CS and CSS were 0.838 and 0.870, respectively, indicating very good internal consistency. Association between continuous variables was assessed using the Spearman correlation. Mean differences between categories were assessed using the Mann-Whitney \u003Cem class=\"italic\"\u003EU\u003C\u002Fem\u003E test for dichotomous variables or the Kruskal-Wallis for more than 2 categories. Differences between categorical variables were assessed using the Chi-square test or Fisher’s exact test. Multivariate analysis was performed using a linear regression model to predict CS and CSS. In all statistical analyses, a \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E value of 0.05 was deemed significant.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec10\" id=\"sec10\"\u003E\u003Ch3 class=\"B\"\u003E Ethics Committee Approval\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E This study was approved by the Institutional Review Board Comitato Etico Territoriale Lombardia 3 (December 18, 2023; study n°3474).\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec results\" data-magellan-destination=\"sec11\" id=\"sec11\"\u003E\u003Ch2 class=\"A\"\u003E Results\u003C\u002Fh2\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec12\" id=\"sec12\"\u003E\u003Ch3 class=\"B\"\u003E Population Characteristics\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E A total of 272 EMSPs answered the survey (RR = 72.3%); 45.2% were women. Mean age was 45.76 years (SD 8.8). A total of 223 were anesthetists (82%), 27 (9.9%) were ER doctors, and 22 (8.1%) had another medical background; 101 (37.1%) worked exclusively in the prehospital setting while 171 (62.9%) worked both at prehospital and in-hospital level. On average, participants had 13.8 years (SD 9.1) of experience working in the prehospital setting.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec13\" id=\"sec13\"\u003E\u003Ch3 class=\"B\"\u003E Legal knowledge of physicians\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E The mean percentage of correct answers in the legal knowledge test was 52.4% (SD 12.3) and the median was 50%; in terms of self-appraisal, 221 respondents (81.3%) did not feel knowledgeable enough (\"nothing\" or “a little”) on the provisions of the Italian legislation on this topic. A low percentage of correct answers in the legal knowledge test was not associated with a perceived poor knowledge of the Italian law \u003Cem class=\"italic\"\u003E(R =\u003C\u002Fem\u003E 0.009, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E = 0.876). There was no association either between the percentage of correct answers and years of experience in the prehospital setting \u003Cem class=\"italic\"\u003E(R =\u003C\u002Fem\u003E 0.012, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E = 0.844), setting of practice, (according to Mann-Whitney \u003Cem class=\"italic\"\u003EU\u003C\u002Fem\u003E test; \u003Cem class=\"italic\"\u003EU\u003C\u002Fem\u003E = 7893.00, \u003Cem class=\"italic\"\u003EW\u003C\u002Fem\u003E = 22 599.00, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E = 0.232) or specialty (according to Kruskal-Wallis test; \u003Cem class=\"italic\"\u003EH\u003C\u002Fem\u003E = 3.151, \u003Cem class=\"italic\"\u003Edf\u003C\u002Fem\u003E = 2, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E = 0.207). Only 80 (29.4 %) and 90 (33.1%) were familiar with, respectively, the legal aspects concerning compulsory treatment and therapeutic necessity procedures. From a legal standpoint, 236 (86.8%) did not know what to do when a patient posed a danger to himself or others.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec14\" id=\"sec14\"\u003E\u003Ch3 class=\"B\"\u003E Physicians’ training\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E A total of 246 (90.5%) rated the training on the management of psychiatric emergencies received so far as \u003Cem class=\"italic\"\u003Einsufficient or scarce.\u003C\u002Fem\u003E Similarly, 195 (71.7%) stated that these emergencies were not at all or only slightly receiving attention from political stakeholders. In addition, 139 (51.1%) were extremely or moderately afraid of being assaulted when dealing with a psychiatric patient with females being significantly more afraid than males (according to Mann-Whitney’s \u003Cem class=\"italic\"\u003EU\u003C\u002Fem\u003E test; \u003Cem class=\"italic\"\u003EU\u003C\u002Fem\u003E = 7790.00, \u003Cem class=\"italic\"\u003EW\u003C\u002Fem\u003E = 15 416.00, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E = 0.02).\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec15\" id=\"sec15\"\u003E\u003Ch3 class=\"B\"\u003E Comfort score and communication skills score\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E For illustration purposes, the results obtained for CS score were categorized into “very low” (11-17 points), “low” (18-24 points), “medium” (25-31 points), “high” (32-38 points), and “very high” (39- 44 points) (\u003Ca class=\"xref fig\" href=\"#fig1\"\u003EFigure 1\u003C\u002Fa\u003E). Likewise, CSS score ranged from “very high” (28-32 points), “high” (23-27 points), “medium” (18-22 points), “low” (13-17 points), and “very low” (8-12 points) (\u003Ca class=\"xref fig\" href=\"#fig2\"\u003EFigure 2\u003C\u002Fa\u003E). Mean CS among respondents was 29.3 (SD 5.5) while mean CSS was 19.1 (SD 3.9). Females showed lower CS (28.43±5.15SD) than males (30.02±5.77SD), according to Mann-Whitney’s \u003Cem class=\"italic\"\u003EU\u003C\u002Fem\u003E test (\u003Cem class=\"italic\"\u003EU\u003C\u002Fem\u003E = 7739.00, \u003Cem class=\"italic\"\u003EW\u003C\u002Fem\u003E = 15 365.50, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E = 0.027). There was no statistical difference between females and males concerning CSS \u003Cem class=\"italic\"\u003E(P =\u003C\u002Fem\u003E 0.078). A higher percentage of correct answers in the legal knowledge test was associated with lower CS (\u003Cem class=\"italic\"\u003ER =\u003C\u002Fem\u003E 0.142, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E = 0.019) but not with a higher CSS (\u003Cem class=\"italic\"\u003ER\u003C\u002Fem\u003E = -0.410, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E = 0.502). Conversely, a higher perceived knowledge of the Italian legislation was associated with a higher CS (\u003Cem class=\"italic\"\u003ER\u003C\u002Fem\u003E = 0.295, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E < 0.001) and higher CSS (\u003Cem class=\"italic\"\u003ER\u003C\u002Fem\u003E = 0.300, \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E < 0.001). Finally, there was no association between sector of practice and either CS or CSS (\u003Cem class=\"italic\"\u003EP =\u003C\u002Fem\u003E 0.200 and \u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E = 0.663, respectively).\u003C\u002Fp\u003E\u003Csection\u003E\u003Cdiv class=\"fig\" data-magellan-destination=\"fig1\" id=\"fig1\"\u003E\n\n\u003Cdiv class=\"figure-thumb\"\u003E\u003Cimg src=\"data:image\u002Fgif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==\" data-src=\"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig1.png?pub-status=live\" class=\"aop-lazy-load-image\" width=\"1605\" height=\"896\" data-original-image=\"\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig1.png\" data-zoomable=\"true\"\u003E\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"caption\"\u003E\u003Cp class=\"p\"\u003E \n\u003C\u002Fp\u003E\u003Cp class=\"p\"\u003E\u003Cspan class=\"label\"\u003EFigure 1\u003C\u002Fspan\u003E Comfort Score (CS).\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E\u003C\u002Fsection\u003E\n\u003Csection\u003E\u003Cdiv class=\"fig\" data-magellan-destination=\"fig2\" id=\"fig2\"\u003E\n\n\u003Cdiv class=\"figure-thumb\"\u003E\u003Cimg src=\"data:image\u002Fgif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==\" data-src=\"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig2.png?pub-status=live\" class=\"aop-lazy-load-image\" width=\"1542\" height=\"825\" data-original-image=\"\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig2.png\" data-zoomable=\"true\"\u003E\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"caption\"\u003E\u003Cp class=\"p\"\u003E \n\u003C\u002Fp\u003E\u003Cp class=\"p\"\u003E\u003Cspan class=\"label\"\u003EFigure 2\u003C\u002Fspan\u003E Communication Skills Score (CSS).\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E\u003C\u002Fsection\u003E\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec16\" id=\"sec16\"\u003E\u003Ch2 class=\"A\"\u003E Multivariate Analyses\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E In order to predict CS and CSS, 2 linear regression models were employed. Variables were entered into the models based on association in the univariate analysis and following negation of multi-collinearity (all variables met the model’s assumptions). The results of these analyses are provided in \u003Ca class=\"xref table\" href=\"#tab1\"\u003ETable 1\u003C\u002Fa\u003E. The results show that for each of the dependent variables (CS and CSS), the strongest predictor is the other dependent variable.\u003C\u002Fp\u003E\u003Cdiv class=\"table-wrap\" data-magellan-destination=\"tab1\" id=\"tab1\"\u003E\n\u003Cdiv class=\"caption\"\u003E\n\u003Cp class=\"p\"\u003E\u003Cspan class=\"label\"\u003ETable 1.\u003C\u002Fspan\u003E Results of linear regression model to predict (1) Comfort Score (CS) and (2) Communication Skills Score (CSS)\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cspan\u003E\n\n\u003Cdiv class=\"figure-thumb\"\u003E\u003Cimg src=\"data:image\u002Fgif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==\" data-src=\"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_tab1.png?pub-status=live\" class=\"aop-lazy-load-image\" width=\"2142\" height=\"888\" data-original-image=\"\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_tab1.png\" data-zoomable=\"true\"\u003E\u003C\u002Fdiv\u003E\n\u003C\u002Fspan\u003E\n\u003Cdiv class=\"table-wrap-foot\"\u003E\n\u003Cp class=\"p\"\u003E Analysis was performed in Enter mode and included only variables associated with the dependent variable in the univariate analysis following negation of multi-collinearity (VIF values<2.5).\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Notes: Gender (Male = 0, Female = 1)\u003C\u002Fp\u003E\n\u003Cdiv class=\"fn-group footnotes\"\u003E\n\u003Cdiv class=\"fn\" data-magellan-destination=\"tab1fn1\" id=\"tab1fn1\"\u003E\n\u003Cp class=\"p\"\u003E\u003Cspan class=\"label\"\u003E\u003Csup class=\"sup\"\u003E****\u003C\u002Fsup\u003E\u003C\u002Fspan\u003E \n\u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E value is significant at the 0.05 level (2-tailed)\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E\n\u003Cp class=\"p\"\u003E \n\u003Cem class=\"italic\"\u003EP\u003C\u002Fem\u003E value is significant at the 0.001 level (2-tailed) CS: Comfort Score CSS: Communication Skills Score.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec17\" id=\"sec17\"\u003E\u003Ch2 class=\"A\"\u003E Limitations\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E This study has several limitations; first, even though results showed that knowledge on legal aspects among EMSPs was low, this study was not designed to inquire about the cause at the root of this fact. Therefore, although it would be reasonable to think that poor training was, at least in part, responsible for these results, lack of interest among EMSPs in the medical treatment of this type of patient could be also a plausible explanation. Actual knowledge was included in the multivariate analyses while self-appraisal of knowledge was not. Therefore, whether perceived knowledge was a predictor of comfort or communication skills remains unknown.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E This survey was not designed to investigate whether EMSPs reckoned their duty to manage psychiatric emergencies to be ethical. In Italy, because EMSPs have usually a background in anesthesia and critical care, psychiatry clearly falls outside their medical background; this could arguably contribute to their lack of preparation and moderately low comfort. Finally, authors did not compare the CS caused by psychiatric emergencies to that caused by other regular EMS emergencies (e.g., cardiac arrest, trauma, etc.). Therefore, even though EMSPs should reasonably be more familiar with the latter, no assumptions can be made.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec discussion\" data-magellan-destination=\"sec18\" id=\"sec18\"\u003E\u003Ch2 class=\"A\"\u003E Discussion\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E The burden of psychiatric emergencies continues to increase\u003Ca class=\"xref bibr\" href=\"#r12\"\u003E\u003Csup class=\"sup\"\u003E12\u003C\u002Fsup\u003E\u003C\u002Fa\u003E with 60% of the cases in need of medical consultation occurring in non-psychiatric facilities.\u003Ca class=\"xref bibr\" href=\"#r13\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Mavrogiorgou, Brüne and Juckel\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E13\u003C\u002Fsup\u003E\u003C\u002Fa\u003E At the time of writing, this was the first manuscript inquiring about knowledge and feelings of EMS practitioners when managing these emergencies in Lombardy.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Participation in this online survey was high compared to the mean response rate reported in literature.\u003Ca class=\"xref bibr\" href=\"#r14\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Wu, Zhao and Fils-Aime\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E14\u003C\u002Fsup\u003E\u003C\u002Fa\u003E This might be because psychiatric emergencies represent a relevant part of the total number of medical prehospital events while, at the same time, pose unique challenges for EMSPs.\u003Ca class=\"xref bibr\" href=\"#r15\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Shaban\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E15\u003C\u002Fsup\u003E\u003C\u002Fa\u003E\u003Csup class=\"sup\"\u003E,\u003C\u002Fsup\u003E \u003Ca class=\"xref bibr\" href=\"#r16\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Roberts\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E16\u003C\u002Fsup\u003E\u003C\u002Fa\u003E In Italy, the medical approach to psychiatric emergencies is subject to specific laws. When patients require immediate mental health treatment and access to the hospital does not occur on voluntary basis, compulsory treatment might be required in the absence of any outpatient treatment alternative.\u003Ca class=\"xref bibr\" href=\"#r3\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Balestrieri, Rucci and Amendola\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E3\u003C\u002Fsup\u003E\u003C\u002Fa\u003E In these cases, cooperation with the police department is mandatory and good knowledge of the legal and administrative procedures is also required to safeguard patient’s dignity and rights while protecting EMSPs professionalism.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E The present study highlighted that knowledge and self-appraisal of knowledge of the Italian legislation on the topic of psychiatric emergencies were low. This was in line with the results obtained by Mothibi et al. and Pajonk et al. in similar studies conducted in South Africa and Germany.\u003Ca class=\"xref bibr\" href=\"#r17\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Pajonk, Bartels and Biberthaler\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E17\u003C\u002Fsup\u003E\u003C\u002Fa\u003E\u003Csup class=\"sup\"\u003E,\u003C\u002Fsup\u003E \u003Ca class=\"xref bibr\" href=\"#r18\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Mothibi and Adefuye\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E18\u003C\u002Fsup\u003E\u003C\u002Fa\u003E Extremely worrisome was that most respondents didn’t know how to clinically address a dangerous patient according to the Italian law.\u003Ca class=\"xref bibr\" href=\"#r7\"\u003E\u003Csup class=\"sup\"\u003E7\u003C\u002Fsup\u003E\u003C\u002Fa\u003E Interestingly, neither long experience doing prehospital emergency care nor practicing exclusively in the prehospital setting were associated with better performance in the knowledge test. At the current stage, the authors cannot give an explanation for these results. These data may support the complexity of these cases and also draw attention to the fact that correct management of psychiatric emergencies cannot rely only upon personal experience but must be supported by solid training.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Italian Law establishes that every physician licensed to practice must be able to first, recognize and assess a patient in acute mental health decompensation and second, choose the safer approach according to his actual clinical condition and in full respect of his rights.\u003Ca class=\"xref bibr\" href=\"#r7\"\u003E\u003Csup class=\"sup\"\u003E7\u003C\u002Fsup\u003E\u003C\u002Fa\u003E However, the vast majority of EMSPs admitted feeling unprepared. Aside of legal aspects, it’s important to remember that psychiatric disorders embrace a big variety of underlying clinical conditions e.g., anxiety, depression, bipolar disorder, substance abuse, and schizophrenia to name but a few. None of these clinical presentations are included in the regular training of EMS doctors in Italy. Without proper training including psychological, clinical, legal, and ethical aspects, the management of psychiatric emergences will continue to be heterogeneous and even harmful for patients and EMSPs.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Interestingly, a cumulative percent of 59, 2% expressed a medium to a very low CS when asked to manage psychiatric patients. Considering that these professionals are required to treat life-threatening emergencies on daily basis (e.g., severe trauma, sudden cardiac arrest or acute respiratory failure), these results deserve special consideration. Psychiatric emergencies can, as such, be grouped into declared suicidal ideation or acute excitement with psychomotor agitation.\u003Ca class=\"xref bibr\" href=\"#r13\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Mavrogiorgou, Brüne and Juckel\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E13\u003C\u002Fsup\u003E\u003C\u002Fa\u003E Therefore, they seldom represent an actual life-threatening emergency unless the patient is actually on the brink of committing suicide. The fact that they lead to psychological stress could arguably be an alarming hint of the global unpreparedness of our target population. It’s also interesting to note that EMSPs who performed better in the legal knowledge test also manifested lower CS. A plausible explanation could be that these professionals were simply more aware of the difficulties entailed by these cases and thus, enhanced their preparedness on the topic. Nevertheless, this explanation should be made with caution, given that actual knowledge did not emerge as a significant predictor of neither CS nor CSS in the multivariate analysis.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E It is worth noting that most EMSPs weren’t confident with their communication skills. When dealing with acute psychiatric disorders, physicians must establish a personal approach with the patient and collect key information faster than in a regular medical interview. Apart from patients’ complaints, observing patients’ behavior and speaking to relatives or patient’s acquaintances to inquire about similar episodes in the past are important.\u003Ca class=\"xref bibr\" href=\"#r13\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Mavrogiorgou, Brüne and Juckel\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E13\u003C\u002Fsup\u003E\u003C\u002Fa\u003E Moreover, a respectful, rational, and empathetic attitude is a cornerstone in the management of psychiatric emergencies as it may determine the therapeutic measures that will follow next.\u003Ca class=\"xref bibr\" href=\"#r13\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Mavrogiorgou, Brüne and Juckel\u003C\u002Fspan\u003E\u003Csup class=\"sup\"\u003E13\u003C\u002Fsup\u003E\u003C\u002Fa\u003E\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Finally, this study aimed to draw attention to the worryingly poor preparedness of EMS when it comes to psychiatric emergencies. Given that the EMS health care personnel in Lombardy is mainly medical and not paramedical, no published training programs seem to match the needs of our target population. Moreover, the challenges posed by acute psychiatric disorders and the specificities of the national and regional jurisprudence impose the development of a training program involving AREU, the police department, and municipalities. In addition, shared guidelines are urgently needed to ensure a good clinical approach and reduce the variability in operational practices.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec conclusions\" data-magellan-destination=\"sec19\" id=\"sec19\"\u003E\u003Ch2 class=\"A\"\u003E Conclusions\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E Knowledge and perceived knowledge of Italian Law concerning psychiatric emergencies was low among EMSPs in Lombardy. There was no association between legal knowledge and work experience in the prehospital setting. The majority of respondents defined the training received on the management of these cases as insufficient and stated that these emergencies deserved more attention. Most doctors were afraid of being physically assaulted. Comfort and self- appraisal of communication skills were low across our target population. Higher legal knowledge was associated with lower comfort but not with a higher perception of communication skills. Higher perceived knowledge of the Italian legislation was associated with a higher comfort and higher perceived communication skills.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"back\"\u003E\n\u003Cdiv class=\"ack\"\u003E\u003Ch2 class=\"A\"\u003E Acknowledgments\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E The authors thank Enzo Griffone, Gianni Maggioni, Grazia Marziale, Marta Norelli, Michele Franchini, Gianluca Dilettoso, Riccardo Cusmà Piccione, Riccardo Maruzzo, Silvia Gennari, Barbara Porro, Alessandra Cozzi, Giovanni De Luca, Barbara Massasogni, Roberto Bertelè, Gaia Radici, Marco Malaffo, Andre Colombini, Elisabetta Samperisi, Chaira Trione, Valerio Bernardi, Elisa Ghezzi, Arianna Albuzzi, Giovanna Durante, Giacomo Ricca, Luigi Dolcino, Paola Plebani, Stefano Vanzini, Gianluca Donati, Matteo Vargiu, Davide La Leggia Davide, Orietta Mapelli, Lara Barbin, Matteo Giacovelli, Cristian Rampin, Franco Lorito, and Pelà Simone for their interest and priceless contribution to ensure the validity and reliabilty of this survey.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"sec20\" id=\"sec20\"\u003E\u003Ch2 class=\"A\"\u003E Author contribution\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E Ripoll-Gallardo A- Designed and directed the project. Wrote the first draft of the manuscript.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Scarpolini E- Contributed to the design of the study. Performed the data collection. Approved the version to be published.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Colzani G- Approved the version to be published.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Biella R- Contributed to the design of the questionnaire. Approved the version to be published.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Offredi I- Contributed to the design of the questionnaire. Approved the version to be published.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Di Silvestre R- Contributed to the design of the questionnaire. Approved the version to be published.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Giannotti C- Approved the version to be published.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Sechi GM- Approved the version to be published.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Fumagalli R- Approved the version to be published.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Fioravanzo R- Approved the version to be published.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Stucchi R- Approved the version to be published.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec funding-statement\" data-magellan-destination=\"sec21\" id=\"sec21\"\u003E\u003Ch2 class=\"A\"\u003E Funding\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E None.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec coi-statement\" data-magellan-destination=\"sec22\" id=\"sec22\"\u003E\u003Ch2 class=\"A\"\u003E Competing interest\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E None.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E",tableOfContent:[{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EObjectives\u003C\u002Fdiv\u003E",url:"sec1"},{level:h,current:a,title:C,url:"sec2"},{level:h,current:a,title:D,url:"sec3"},{level:h,current:a,title:E,url:"sec4"},{level:h,current:a,title:C,url:"sec5"},{level:h,current:a,title:D,url:"sec11"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EMultivariate Analyses\u003C\u002Fdiv\u003E",url:"sec16"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003ELimitations\u003C\u002Fdiv\u003E",url:"sec17"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EDiscussion\u003C\u002Fdiv\u003E",url:"sec18"},{level:h,current:a,title:E,url:"sec19"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EAuthor contribution\u003C\u002Fdiv\u003E",url:"sec20"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EFunding\u003C\u002Fdiv\u003E",url:"sec21"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003ECompeting interest\u003C\u002Fdiv\u003E",url:"sec22"}],footnotes:[],fulltextNotes:[],references:[{id:"r1",displayNumber:F,existInContent:c,content:"\u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003ECénat\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EJM\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EMoshirian Farahi\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003ESMM\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EDalexis\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003ERD\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E \u003Cspan class=\"etal\"\u003Eet al.\u003C\u002Fspan\u003E \u003Cspan class=\"article-title\"\u003EThe global evolution of mental health problems 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class=\"surname\"\u003ELuo\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EM\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EGuo\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EL\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EYu\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EM\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E \u003Cspan class=\"etal\"\u003Eet al.\u003C\u002Fspan\u003E \u003Cspan class=\"article-title\"\u003EThe psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public—a systematic review and meta-analysis\u003C\u002Fspan\u003E. \u003Cspan class=\"source\"\u003EPsychiatry Res.\u003C\u002Fspan\u003E \u003Cspan class=\"year\"\u003E2020\u003C\u002Fspan\u003E;\u003Cspan class=\"volume\"\u003E291\u003C\u002Fspan\u003E:\u003Cspan 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href=https:\u002F\u002Fwww.ncbi.nlm.nih.gov\u002Fpubmed\u002F32563745\u003EPubMed\u003C\u002Fa\u003E",item:[{googleScholarLink:"https:\u002F\u002Fscholar.google.com\u002Fscholar_lookup?title=The+psychological+and+mental+impact+of+coronavirus+disease+2019+(COVID-19)+on+medical+staff+and+general+public%E2%80%94a+systematic+review+and+meta-analysis&author=Luo+M&author=Guo+L&author=Yu+M&publication+year=2020&journal=Psychiatry+Res.&volume=291&doi=10.1016%2Fj.psychres.2020.113190",openUrlParams:{genre:g,atitle:K,jtitle:L,title:L,volume:"291",artnum:"6734323121c8183ee4e767c1",spage:"113190",epage:e,date:"2020",sid:f,aulast:b,aufirst:b,doi:M,au:b},innerRefId:"ref2",title:K,pubMedId:"32563745",doi:M,crossRefLink:"https:\u002F\u002Fdx.doi.org\u002F10.1016\u002Fj.psychres.2020.113190",pubMedLink:"https:\u002F\u002Fwww.ncbi.nlm.nih.gov\u002Fpubmed\u002F32563745"}]},{id:"r3",displayNumber:N,existInContent:c,content:"\u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EBalestrieri\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EM\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003ERucci\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EP\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EAmendola\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003ED\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E \u003Cspan class=\"etal\"\u003Eet al.\u003C\u002Fspan\u003E \u003Cspan class=\"article-title\"\u003EEmergency psychiatric consultations during and after the COVID-19 lockdown in Italy. 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class=\"surname\"\u003EMothibi\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EJM\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, Jama M, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EAdefuye\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EAO\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E. \u003Cspan class=\"article-title\"\u003EAssessing the knowledge of emergency medical care practitioners in the Free State, South Africa, on aspects of pre-hospital management of psychiatric emergencies\u003C\u002Fspan\u003E. \u003Cspan class=\"source\"\u003EPan Afr Med J.\u003C\u002Fspan\u003E \u003Cspan class=\"year\"\u003E2019\u003C\u002Fspan\u003E;\u003Cspan class=\"volume\"\u003E33\u003C\u002Fspan\u003E:\u003Cspan class=\"fpage\"\u003E132\u003C\u002Fspan\u003E.\u003Ca class='ref-link' target='_blank' aria-label='CrossRef link for Assessing the knowledge of emergency medical care practitioners in the Free State, South Africa, on aspects of pre-hospital 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psychiatric emergencies' href=https:\u002F\u002Fwww.ncbi.nlm.nih.gov\u002Fpubmed\u002F31558931\u003EPubMed\u003C\u002Fa\u003E",item:[{googleScholarLink:"https:\u002F\u002Fscholar.google.com\u002Fscholar_lookup?title=Assessing+the+knowledge+of+emergency+medical+care+practitioners+in+the+Free+State%2C+South+Africa%2C+on+aspects+of+pre-hospital+management+of+psychiatric+emergencies&author=Mothibi+JM&author=Adefuye+AO&publication+year=2019&journal=Pan+Afr+Med+J.&volume=33&doi=10.11604%2Fpamj.2019.33.132.18426",openUrlParams:{genre:g,atitle:aw,jtitle:ax,title:ax,volume:"33",artnum:"6734323121c8183ee4e767d1",spage:"132",epage:e,date:"2019",sid:f,aulast:b,aufirst:b,doi:ay,au:b},innerRefId:"ref18",title:aw,pubMedId:"31558931",doi:ay,crossRefLink:"https:\u002F\u002Fdx.doi.org\u002F10.11604\u002Fpamj.2019.33.132.18426",pubMedLink:"https:\u002F\u002Fwww.ncbi.nlm.nih.gov\u002Fpubmed\u002F31558931"}]}],figures:[{contentId:"fig1",label:"Figure 1",description:"\u003Cspan class=\"p\"\u003EComfort Score (CS).\u003C\u002Fspan\u003E",thumbnailSrc:az,enlargedSrc:az,attrib:[]},{contentId:"fig2",label:"Figure 2",description:"\u003Cspan class=\"p\"\u003ECommunication Skills Score (CSS).\u003C\u002Fspan\u003E",thumbnailSrc:aA,enlargedSrc:aA,attrib:[]},{contentId:"tab1",label:"Table 1.",description:"\u003Cspan class=\"p\"\u003EResults of linear regression model to predict (1) Comfort Score (CS) and (2) Communication Skills Score (CSS)\u003C\u002Fspan\u003E",thumbnailSrc:"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary-alt:20241113045948-93397-mediumThumb-png-S1935789324001824_tab1.jpg",enlargedSrc:"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary-alt:20241113045948-12907-optimisedImage-png-S1935789324001824_tab1.jpg",attrib:[]}]},pdf:{standardResolution:{fileUrl:"\u002Fcore\u002Fservices\u002Faop-cambridge-core\u002Fcontent\u002Fview\u002F17900D5E02942E7EFF46C8044C7A121C\u002FS1935789324001824a.pdf\u002Fmanagement-of-psychiatric-emergencies-and-associated-comfort-among-ems-physicians-in-lombardy-italy-a-cross-sectional-study.pdf",fileSizeInMb:.44,articleTitle:q,slugTitle:"management-of-psychiatric-emergencies-and-associated-comfort-among-ems-physicians-in-lombardy-italy-a-cross-sectional-study"},highResolution:e,media:e},classification:[],supplementaryMaterials:[],relations:{corrections:[],correctionsOriginals:[],retractions:[],retractionsOriginals:[],addendums:[],addendumsOriginals:[],hasAnyRelations:a,hasAnyOriginalArticle:a},settings:{hasAccess:c,isOpenAccess:a,displayRightsLink:c,shouldDisplayCrossMark:a,shouldDisplayNasaAds:a,suppressPdf:a,isShareable:c,isAnnotationsEnabled:a,disableArticleCommentary:a,displayArticleCommentaryAsDiscussionLinks:a,isCommentsEnabled:a,hasContent:c,shouldDisplaySubmitContent:a,isResearchDirections:a,isQuestionCollection:a,isMathjaxEnabled:a},citationCount:s,openUrlParams:"?genre=article&atitle=Management%20Of%20Psychiatric%20Emergencies%20and%20Associated%20Comfort%20Among%20EMS%20Physicians%20in%20Lombardy%2C%20Italy%3A%20A%20Cross-Sectional%20Study&jtitle=Disaster%20Medicine%20and%20Public%20Health%20Preparedness&title=Disaster%20Medicine%20and%20Public%20Health%20Preparedness&date=2024&volume=18&artnum=e267&sid=https%3A%2F%2Fwww.cambridge.org%2Fcore&aulast=Ripoll-Gallardo&aufirst=Alba&doi=10.1017\u002Fdmp.2024.182",ecommerceProducts:{digitalSku:l,paperBackSku:e,hardBackSku:e},subject:[],permissionUrl:"https:\u002F\u002Fs100.copyright.com\u002FAppDispatchServlet?publisherName=CUP&publication=DMP&title=Management%20Of%20Psychiatric%20Emergencies%20and%20Associated%20Comfort%20Among%20EMS%20Physicians%20in%20Lombardy%2C%20Italy%3A%20A%20Cross-Sectional%20Study&publicationDate=13%20November%202024&author=Alba%20Ripoll-Gallardo%2C%20Elisa%20Scarpolini%2C%20Giacomo%20Colzani%2C%20Roberto%20Biella%2C%20Ilaria%20Offredi%2C%20Roberto%20Di%20Silvestre%2C%20Claudia%20Giannotti%2C%20Giuseppe%20Maria%20Sechi%2C%20Roberto%20Fumagalli%2C%20Rita%20E%20Fioravanzo%2C%20Riccardo%20Stucchi&copyright=%C2%A9%20The%20Author(s)%2C%202024.%20Published%20by%20Cambridge%20University%20Press%20on%20behalf%20of%20Society%20for%20Disaster%20Medicine%20and%20Public%20Health%2C%20Inc&contentID=10.1017%2Fdmp.2024.182&startPage=&endPage=&orderBeanReset=True&volumeNum=18&issueNum=&oa="},breadcrumbs:[{name:"Home",url:"\u002Fcore"},{name:"Journals",url:"\u002Fcore\u002Fpublications\u002Fjournals"},{name:m,url:x},{name:z,url:A},{name:"Management 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AAT Milano, Agenzia Regionale Emergenza Urgenza (AREU), Dipartimento di Emergenza e Accettazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy","Azienda Regionale Emergenza Urgenza (AREU) Lombardia, Milano, Italy","S1935789324001824","Disaster Medicine and Public Health Preparedness","article_dmp_ind_pur","2022","Cochrane Database Syst Rev.","Management Of Psychiatric Emergencies and Associated Comfort Among EMS Physicians in Lombardy, Italy: A Cross-Sectional Study","Roberto",0,"11","The implications of mental health call outs on paramedic practice. Dep Paramed Soc Health Sci","03D33CB340FE0698DCD12DE4F229787A","disaster-medicine-and-public-health-preparedness","\u002Fcore\u002Fjournals\u002Fdisaster-medicine-and-public-health-preparedness","18","Volume 18","\u002Fcore\u002Fjournals\u002Fdisaster-medicine-and-public-health-preparedness\u002Fvolume\u002FB4BDDE64E8E1C7D85A7C176762D9E977","en","\u003Cdiv class=\"toc-title\"\u003EMethods\u003C\u002Fdiv\u003E","\u003Cdiv class=\"toc-title\"\u003EResults\u003C\u002Fdiv\u003E","\u003Cdiv class=\"toc-title\"\u003EConclusions\u003C\u002Fdiv\u003E","1","The global evolution of mental health problems during the COVID-19 pandemic: a systematic review and metaanalysis of longitudinal studies","J Affect Disord.","10.1016\u002Fj.jad.2022.07.011","2","The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public—a systematic review and meta-analysis","Psychiatry Res.","10.1016\u002Fj.psychres.2020.113190","3","Emergency psychiatric consultations during and after the COVID-19 lockdown in Italy. A multicentre study","Front Psychiatry.","12","2021","10.3389\u002Ffpsyt.2021.697058","Mental health in Italy after two years of COVID-19 from the perspective of 1281 Italian physicians: looking back to plan forward","Ann Gen Psychiatry.","10.1186\u002Fs12991-022-00410-5","Communication skills training for mental health professionals working with people with severe mental illness","6","Crisis intervention for people with severe mental illnesses","7","unknown","8","Navigating into the unknown: exploring the experience of exposure to prehospital emergency stressors: a sequential explanatory mixed-methods","BMC Emerg Med.","2023","10.1186\u002Fs12873-023-00906-7","Psychosocial work stress and occupational stressors in emergency medical services","Healthcare (Basel).","10.3390\u002Fhealthcare11070976","Delphi methodology in health care research: How to decide its appropriateness","World J Methodol.","10.5662\u002Fwjm.v11.i4.116","Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies","Clin Epidemiol.","10.1016\u002Fj.jclinepi.2013.12.002","The management of psychiatric emergencies","Dtsch Arztebl Int.","Response rates of online surveys in published research: a meta-analysis","Comp Hum Behav Rep.","Mental health assessments in paramedic practice: a warrant for research and inquiry into accounts of paramedic clinical judgment and decision-making","J Emerg Prim Health Care.","Psychiatric emergencies in preclinical emergency service; incidence, treatment and evaluation by emergency physicians and staff","Nervenarzt.","10.1007\u002Fs001150170047","Assessing the knowledge of emergency medical care practitioners in the Free State, South Africa, on aspects of pre-hospital management of psychiatric emergencies","Pan Afr Med J.","10.11604\u002Fpamj.2019.33.132.18426","https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig1.png","https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20241113045926725-0012:S1935789324001824:S1935789324001824_fig2.png"));</script><script src="/core/page-component/06cd607.js" defer></script><script src="/core/page-component/20147ec.js" defer></script><script src="/core/page-component/722ace3.js" defer></script><script src="/core/page-component/6f4302c.js" defer></script> </div> </div> <div id="article-new-home-productCitations" class="product-citations-modal reveal-modal medium" data-reveal role="dialog" aria-labelledby="article-new-home-citedByModalHeader"> <div class="header"> <div class="heading_07 margin-bottom" id="article-new-home-citedByModalHeader">Cited by</div> </div> <div class="citation-content"> <div 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class="volume-issue">Volume 18</li> <li class="author"> <a href="/core/search?filters%5BauthorTerms%5D=Alba Ripoll-Gallardo&eventCode=SE-AU" class="more-by-this-author ">Alba Ripoll-Gallardo</a><a target="_blank" class="orcid-logo " href="https://orcid.org/0000-0003-4719-7333" aria-label="Open the ORCID record for Alba Ripoll-Gallardo in new tab/window"></a> <sup data-affiliation-id="a1" class="">(a1)</sup><span class="separator ">, </span><a href="/core/search?filters%5BauthorTerms%5D=Elisa Scarpolini&eventCode=SE-AU" class="more-by-this-author ">Elisa Scarpolini</a> <sup data-affiliation-id="a1" class="">(a1)</sup><span class="separator ">, </span><a href="/core/search?filters%5BauthorTerms%5D=Giacomo Colzani&eventCode=SE-AU" class="more-by-this-author ">Giacomo Colzani</a> <sup data-affiliation-id="a1" class="">(a1)</sup><span class="separator ">, </span><a href="/core/search?filters%5BauthorTerms%5D=Roberto Biella&eventCode=SE-AU" class="more-by-this-author ">Roberto Biella</a> 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