FOR HYPERLINKS TO WORK CONSISTENTLY, PLEASE DOWNLOAD PRON ONTO DESKTOP Return to Top HMC PRON Revised 8/23/2021 Return to Top HMC Inpatient Psychiatry Links COVID Information EPIC SIGN-IN SECURE CHAT CORES ORDERS PATIENT LISTS CSSRS GENERAL ON CALL INFORMATION Sign-out Short Call On-Call Pager Real Time Locating System Devices Illness Medical Students On-Call On-Call Amenities CL and Chief Resident Offices ON CALL RESPONSIBILITIES Cross-Cover Restraints and Seclusion Admissions Psychiatry Consultation Consult Note Types PES Triage of Care On-Call Tips Attending Coverage When to Call Attending Who is my attending? No PES Attending Patient Movements Discharge Process (DC Summary) Transfers within HMC Psychiatry Units 5MB to 5WB Considerations HMC Inpatient to Med/Surg HMC CL (Med/Surg) to HMC Inpatient OSH to HMC Inpatient HMC CL to OSH HMC CL to NWH Inpatient HMC Inpatient to NWH Inpatient HMC PES to Seattle VA Inpatient Psychiatry Details Rapid Responses AMA Discharge Vulnerable Patients Sexual Assaults Patient on Patient Physical Assault Patient on Provider Physical Assault Discharge to Jail Patient Elopement Consult-Liaison Details Consult patients located in the ED After Hours Transfers Psychiatric Emergency Services Initial Meet & Greet PES Sign-Out General approach to PES Eval Discharging to CDF & CRP Calls about direct admits to PES ED to PES Transfer PES to ED Transfer Doc to Doc info 10.77 Patients Safety Dispo from PES Appendix Disaster preparedness What if a patient dies? Phone Calls from Patients Legal Guardianship & patient admission DCR Referrals and ITA Law Ricky’s Law How to write an affidavit Sample Affidavits Poor faith voluntary What if the DCR does not detain my patient? Hospital Pre-authorization AMA Algorithm from CL CORES Signout guidelines Affidavit template EKG Policy Medical Students (and their notes) Anesthesia-Assisted (sedation) MRIs Epic Resources Proxy DCR Referrals during HMC Call
Transcript
FOR HYPERLINKS TO WORK CONSISTENTLY, PLEASE DOWNLOAD PRON ONTO DESKTOP
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HMC PRON Revised 8/23/2021
Return to Top HMC Inpatient Psychiatry Links COVID Information EPIC SIGN-IN SECURE CHAT CORES ORDERS PATIENT LISTS CSSRS GENERAL ON CALL INFORMATION Sign-out Short Call On-Call Pager Real Time Locating System Devices Illness Medical Students On-Call On-Call Amenities CL and Chief Resident Offices ON CALL RESPONSIBILITIES Cross-Cover Restraints and Seclusion Admissions Psychiatry Consultation Consult Note Types PES Triage of Care On-Call Tips Attending Coverage When to Call Attending Who is my attending? No PES Attending Patient Movements Discharge Process (DC Summary) Transfers within HMC Psychiatry Units 5MB to 5WB Considerations HMC Inpatient to Med/Surg HMC CL (Med/Surg) to HMC Inpatient OSH to HMC Inpatient HMC CL to OSH HMC CL to NWH Inpatient HMC Inpatient to NWH Inpatient HMC PES to Seattle VA
Inpatient Psychiatry Details Rapid Responses AMA Discharge Vulnerable Patients Sexual Assaults Patient on Patient Physical Assault Patient on Provider Physical Assault Discharge to Jail Patient Elopement Consult-Liaison Details Consult patients located in the ED
After Hours Transfers Psychiatric Emergency Services Initial Meet & Greet PES Sign-Out
General approach to PES Eval Discharging to CDF & CRP Calls about direct admits to PES ED to PES Transfer PES to ED Transfer Doc to Doc info 10.77 Patients Safety Dispo from PES
Appendix Disaster preparedness What if a patient dies?
Phone Calls from Patients Legal Guardianship & patient admission DCR Referrals and ITA Law Ricky’s Law How to write an affidavit Sample Affidavits Poor faith voluntary What if the DCR does not detain my patient? Hospital Pre-authorization AMA Algorithm from CL CORES Signout guidelines Affidavit template EKG Policy Medical Students (and their notes) Anesthesia-Assisted (sedation) MRIs Epic Resources Proxy DCR Referrals during HMC Call
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HMC PRON TIP SHEET Who is my attending?
1. Weekday: Doc of the Day until 5 PM; 5 PM – 8 PM on-call attending 2. Weekend: 8 AM – 5 PM 5WA attending; 5 PM – 8 AM on-call attending
a. Check the email sent to you from Jes Olson about call. Lists attending on call. b. On Sundays after 6pm your attending is the UWMC/HMC on call attending.
3. How to contact attending if attending does not contact you? a. Page through operator. b. Text page through Links&Reports -> HMC paging
VOICEMAIL ON PAGERS
• The on-call pager does not have voicemail capabilities.
• To retrieve voicemails from your personal pager, dial the pager’s number, enter 0, then the PIN, and 3 to listen to messages.
CALLS FROM OUTSIDE PROVIDERS Direct outside providers to call 877-WA-PSYCH (877-927-7924) and, after a short intake with a UW health navigator, are connected to a UW psychiatrist. At the conclusion of the conversation, the UW psychiatrist will send a brief written documentation of the recommendations to the caller via email. The PCL is available to providers working in primary care clinics, community hospitals, emergency departments, county and municipal correctional facilities, and evaluation and treatment centers. The line is now available and staffed 24/7. HMC Inpatient Psychiatry Links One Drive folder: HMC Inpatient Psychiatry Resources -CSSR info, Affidavit template, DCR referral considerations -Orientation resources -Inpatient psychiatry guide
CL office: -walkthrough the center tower through the 5 east clinic, past the elevators; office is on the right (west): -CL office code: 111333 -Printer room code: 345-234 Epic Hotline: 206-520-2255
Social Work C/L social worker (M-F) 744-2170 PES social worker (24/7):744-2649 Saturday Inpt Psych SW (8-4:40): 680-8737 pager Med/Surg social worker (eve & wkds) 986-2576 pager
-Short call guide -Vacation and leave policy -Outlook efficiency tips -Education progress and feedback plan -ITA 101 -ORCA folder (set up guide, discharge info, auto text/dot phrases, powernotes) -Educational resources -Master H&P -Psychopharm resources -Medical student guide (can give to students) Master Schedule: Master Schedule Doc of Day Calendar: Doc of Day Calendar Link HMC Short Call calendar: Short call HMC PRON: on MedHub https://uw.medhub.com/index.mh Spin Fusion log-in link: https://www.spinfusion.com/SpinSchedules/login
COVID INFORMATION
1. All COVID+ patients should be signed out for everyone’s situational awareness. Please include
COVID status in CORES.
2. COVID+ patients on CL:
a. First attempt to call on phone while laying eyes on patient from doorway/window. This
should work most of the time. If this fails, discuss with attending.
b. If absolutely necessary to see patient in room, ask for instructions from staff in
donning/doffing PPE.
3. Links:
a. For Psychiatry residency-wide COVID policies: https://uwnetid-
a. Eye Protection: must be worn when directly caring for patients; obtain at 5W nursing stations.
b. Masks: must be worn at all times unless you are 100% alone in a workroom; obtain at 5W
nursing stations.
EPIC SIGN-IN When you log-in, you should select D1 IP Resident/Fellow (or something similar - be sure it has D1). The message will only pop up on initial login after a security update has occurred. Context: H IP Psychiatry (use even for PES and Consults) SECURE CHAT Best practice for secure chat is to:
1. Set as unavailable. This is highly recommended if you don't have Haiku (mobile Epic app). Set an automatic response such as "Not using secure chat. Please page me." This will alert whoever has sent you a secure chat that you are not receiving secure chats and that you should be paged. See this document about how to set an automatic response in secure chat: Automatic Response in Secure Chat
2. Set as available only if you have Epic Haiku on your phone. Be sure in phone settings to have lock screen notifications, notification center, banner notifications, and sounds turned on for Haiku so you don't miss an important message. Turning on these notifications will alert you to secure chats more easily than a desktop computer and will allow you to communicate away from your computer.
Either way RNs should NOT be asking for orders or communicating vital information via Secure Chat, including but not limited to change in vital signs, patient fall, medical issues, asking to leave AMA. They should page you. If RNs ask you for an order or communicate vital information via Secure Chat, please let them know this is inappropriate and email your chief resident that this occurred. See this document Paging vs Secure Chat Communication for more information about paging versus secure chat and feel free to share with nursing. CORES Sign into CORES - sign into patients as you did in ORCA. The first time you do this, re-add your pager to CORES. For help, see How to add pager to CORES CORES Do's and Don'ts In brief, you cannot add or remove patients through CORES, must do in Epic. See “PATIENT LISTS” section below. ORDERS
• 1:1 monitor and level status: Type “supervision” into Orders box. Select Level 1, Level 2, or 1:1 monitor.
• Restraints: type Restraint into Orders box.
• Seclusion: type Seclusion into Orders box. Note that Seclusion is now a separate order from Restraints.
• Routine phlebotomy labs are draw within two hours (STAT orders should be placed for draws needed before two-hour timeframe)
• Do not order q8Hr/q6Hr/q12hr meds. Instead, order “TID” /"QID"/"BID" as this allows nursing staff to give the meds during standard medication administration times
• Standard medication administration times. You can adjust ‘frequency’ by click magnifying glass. o QD and qAM = 0900 o BID = 0900 and 2100 o TID = 0900, 1300, 2100
● To adjust an existing medication, go to Orders tab and click Modify to the right of the order.
● When ordering or adjusting a medication, be sure to pay attention to when the medication will start.
o If you would like the patient start a medication right away, click ‘Include Now’ button. o If you would like the patient to start a medication tomorrow, click ‘Tomorrow’ button. o If you need to give the medication ASAP, click ‘STAT’ button. o You can adjust when the medication starts by clicking on the clock in the ‘First Dose’ field. Put in the time you want the medication to start.
o You can adjust the Scheduled Times by clicking ‘Adjust Schedule’. Type in the
adjusted times in the box that pops up.
o Always double check medication orders by looking at the Med History tab under
Summary. The new or adjusted medications should be listed with their start times. Be
sure to Refresh if you don’t see these orders.
Note: You may need to put in an authorizing provider - this should be fixed now. However, if not, call the Epic Hotline (206-520-2255). Put in your on-call attending. The order does not need to be signed by them in order to be active. PATIENT LISTS Favorite the following lists by right-clicking on a list, then clicking Save as Favorite. See video: https://youtu.be/CzBCtRefUr0 Recommended lists to favorite: Under HMC Hospital -> HMC Units 5WA, 5WB, 5MB, PES – Psych Emergency Services, Emergency Department (when in PES) Under HMC Services -> HMC Psychiatry: H Psychiatry Consult/Liaison, H Psychiatry I/II/III/IV/V/VI/VII/VIII/IX Adding patients to a list/CORES: you cannot add via CORES even if the nurse says ‘please add patient to cores.’ Find the patient on the correct unit, right-click on Assign Teams. Type the correct
team, e.g. Psychiatry I, in the text box and click Accept. The Epic lists autopopulate the CORES lists. See this video for more information about changing the patient’s assigned team: https://youtu.be/CzBCtRefUr0
CSSRS: Columbia Suicide Severity Rating Scale Secondary Screen
• All patients at HMC (ED/PES/admitted) will undergo the CSSRS. If they screen HIGH, a social worker, psychiatry resident, psychiatry attending, or psychiatry ARNP needs to perform a safety assessment of the patient and discuss the patient’s need for 1:1 sitter.
• For patients on inpatient psychiatry: o From PES: the PES provider should have performed the secondary screen. Look in the
PES note or PES SW notes. If no safety assessment and/or no discussion of need for 1:1, you must:
▪ See the patient and perform safety assessment. ▪ Discuss need for 1:1 with your on-call attending. ▪ Document in a cross-cover Progress note using the phrase below. Document in a
cross-cover Progress note using SmartPhrase - find HMCPSYCHCSSRS from Chief Resident
o From CL or OSH: Psych RN will perform CSSRS. If screens HIGH, you must: ▪ See the patient and perform safety assessment. ▪ Discuss need for 1:1 with your on-call attending. ▪ Document in a cross-cover Progress note using SmartPhrase - find
HMCPSYCHCSSRS from Chief Resident
• For PES patients: o Perform safety assessment in PES note. o If patient will be admitted to HMC Psychiatry, please discuss need for 1:1 sitter with
following phrase: Patient screened high on previous CSSRS screen. Patient has been reassessed and ***does/does not*** need a 1:1 monitor. Patient is appropriate for level of care on inpatient psychiatry and continues to require admission to inpatient psychiatry for safety and stabilization.
• For CL patients: o You will need to see the patient as a new consult (unless patient already has a new CL
note during that hospital admission). The primary team must place a consult order like any new consult.
o Write a full Initial CL note – no brief notes! Be sure to include safety assessment. o Discuss need for 1:1 with you attending. o Communicate need for 1:1 with the team.
• Nurses should perform primary screen; physician, ARNP, PA, SW should perform secondary screen.
GENERAL ON-CALL INFORMATION
● All call at HMC is in house call, meaning that the resident on call is always at the hospital ● If you are on AM call you will mostly be taking care of floor issues and consults
● If you are on PM call you will mostly be doing PES work Start/Finish Times
● Short Call (covered by HMC inpatient residents) o M,T,W,F: 1:00pm – 8:00pm o Thursday/didactics: 2:00pm – 8:00pm
● Night float/Night call: 8:00pm to 8:00am ● Weekend & Holiday Day call: 8:00am to 8:00pm
Sign-out Weeknight (nightfloat):
● You should be in the resident workroom (5th floor) ready to get sign-out from the short call resident at 7:45 pm.
● Morning sign-out takes place at 7:45 am in the resident workrooms where the day team residents (or attendings) will be present to get sign-out.
● Call the consult service (4-5927) (or visit in person) to give sign-out, including any new referrals. Be sure to update CORES as appropriate.
● Don’t forget to leave the on-call pager in the wire basket in the work room! Weekend day/night call and holidays:
● The oncoming resident will meet the off going resident in the resident workroom at 7:45 to get sign out on the consult and inpatient teams.
● For consults, update CORES and OneDrive as appropriate to include any new referrals and other updates to help facilitate sign out.
● Don’t forget to hand off the pager to the oncoming resident! What if the next resident has not shown up?
● If the next resident has not arrived by the end of your shift, page the resident.
● If no response, call the resident at home (cell #s available on MedHub => psychiatry residency documents => personal contacts list)
● If you cannot contact the next resident by ½ hour after the end of your shift, start by paging the 1st backup resident. If unable to get in touch with the 1st back-up, then call 2nd back-up.
● Do not leave Harborview until the next resident – either the scheduled on-call resident or one of the backup residents – has arrived.
**Report all such situations to the HMC Inpatient Chief Resident!** Short Call
● Hours o MTWF from 1pm-7:45pm and Thurs from 2pm-7:45pm
▪ Exception: Tuesdays in July-Aug where both new R2s and R1s have didactics. Short call is expected to cover from 12:30pm – 7:45pm.
o Short call resident remains in-house (with access to their own personal pager and the on-call pager) for duration of shift
o Short call resident signs out to the night-float resident at 7:45pm o What if I am on short call and ill? Please page/text the HMC inpatient chief. HMC
inpatient chief will try to arrange a trade with another resident. If that’s not possible we will ask the float resident to cover. If that’s not possible we will as the risk resident to come in to cover short call.
▪ Note: if you get sick or need to leave during the 5pm-8pm period, you will need to call in risk resident.
● Short Call Schedule o The HMC inpatient chief will assign short call, balancing didactics, pre-assigned
vacations, and continuity clinic schedules. Residents' short call will be tracked to distribution short call as equitably as possible over the total of R1 and R2 year.
o Residents on the inpatient service will be provided with short call assignments no later than 1 month in advance.
o If a resident wants to trade a short call shift due to, the resident is responsible for trading with a co-resident. Once a trade has been finalized, email the chief resident.
o Schedules: HMC Short Call Calendar with Trainers
● Responsibilities o 1:00-5:00pm
▪ Coverage for all floor teams that have been signed out to them.
▪ Staffing: staff all patient-care issues with the patient’s primary team’s own attending, or if unavailable the Doc-of-the-Day.
- First priority: all inpatient teams (all teams are expected to sign out at this time – please page the attending for any attending-led team that has not signed out to you by 5:00pm to get sign out)
- Second Priority: Consults. See any urgent consult that cannot be triaged to nightfloat resident. Do not start a new consult after 6:30 PM unless very urgent. Always discuss triage with your attending if needed.
o Note: short-call resident does NOT work in the PES
● Admissions (See Patient Movement section in PRON) o HMC PES to HMC Inpatient: Orders and H&P written by the PES. Short call resident
responsible for adding patient to CORES, updating CORES, and reviewing orders to ensure no errors and that orders are complete.
o UW-ML or UW-NW ED/CL Service: Orders written by sending team. Short call resident responsible for assessing patient, physical exam, ROS, writing H&P, adding patient to CORES, updating CORES, and reviewing orders to ensure no errors and that orders are complete. If after 7 PM, can defer patient assessment and H&P to nightfloat resident.
▪ Note: If the receiving team’s resident is still in house, the receiving team’s resident is responsible for caring for the patient (assessing patient, physical exam, ROS, writing H&P, adding patient to CORES, updating CORES, and reviewing orders to ensure no errors and that orders are complete).
● Short Call Training for R1s and New R2s: o Senior residents who are doing short call training will come to resident workroom at 3 PM
and work with interns until 8:00 PM. They will have a day off their other clinical duties for this.
o To be fully trained on short call, a resident will have had at least 2 training calls of any combination of short call training, HMC AM training call, or HMC PM training call
o The focus of short call training should be on: ▪ Medical issues on the psychiatric unit (i.e. how to handle a rapid response) ▪ Consults (documentation, triaging, and basics) ▪ Safe and standardized hand-offs using I-PASS
On-Call Pager
● At the start of your shift, please make sure to pick up the On-Call Pager from the prior resident. ● The On-Call Pager (663-9595) has numeric paging capabilities.
● Questions or issues with the pager should be directed to HMC operator and/or HMC communications.
RTLS (Real Time Locating System) Devices
• Each inpatient resident is assigned a RTLS device. These devices must be returned to the chief resident when the resident rotates off the HMC inpatient service.
• This device tracks the wearer’s location only within each psychiatric unit. The device has an emergency button that when pushed alerts staff to the wearer’s location. The button should be pushed if needing emergent assistance if you are unable to signal verbally.
• Two RTLS devices are reserved for the on-call resident and on-call training resident. On-Call Resident Responsibilities Cross-cover evaluation and notes
• Evaluations for both medical and psychiatric issues. o See a patient anytime a RN requests an evaluation. See patient within 15 minutes. o You must respond immediately for rapid responses or code blues. o You do not need to respond code greys unless a RN requests assessment. o You can page medicine consults through the hospital operator for urgent medical issues or
for need to transfer to medicine. o EKGs: Review all new EKGs. Sign and date.
• Notes: WRITE A NOTE EVERY TIME YOU SEE A PATIENT
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o Generic: use SmartPhrase HMCPSYCHCROSSCOVER ▪ Epic SmartPhrases: If a SmartPhrase has not been shared with you by the chief
resident, go find the smart phrase under the chief resident’s name and add yourself to it. See this video for help:
o Post-fall: Go to Post-Fall tab (under dropdown arrow on far right if it's not visible). Under Significant Event Note, click green plus arrow "Create Note." Type "Fall" in Insert Smart Text. Or use SmartPhrase HMCPSYCHFALL
▪ See Epic Tabs video for info on how to find the Post-Fall tab: https://youtu.be/68s1lt3IUNo
o Note type: No Crosscover note type in Epic ▪ For basic issues e.g. “called for HR 102...reviewed chart and is stable, will defer to
primary team...” should go under Progress note type. ▪ Falls, assaults, rapid response, significant medication reactions (most things that
would be staffed with the attending) use Significant Event note type.
• Restraints and seclusion orders o Restraints and seclusion are now separate orders (unlike ORCA). o Be sure to order age 18+ and violent restraints. o No need to write a restraint note. o It is good practice to see the patient after restraints have been initiated but not required
unless RNs have concerns. o Renewal: RN will send to your Epic in-basket and should page you.
• CORES o Update sign-out with any changes that have happened during your shift. o Add new patients from the PES to CORES and update their sign-out.
• Admissions o HMC PES to HMC Inpatient: Orders and H&P written by the PES. On-call resident
responsible for adding patient to CORES, updating CORES, and reviewing orders to ensure no errors and that orders are complete.
o UW-ML or UW-NW ED/CL Service: Orders written by sending team. ▪ After 3 PM: On-call resident responsible for assessing patient, physical exam, ROS,
writing H&P, adding patient to CORES, updating CORES, and reviewing orders to ensure no errors and that orders are complete.
▪ Before 3 PM: On-call attending for the specific unit to which patient was transferred is responsible for assessing patient, physical exam, ROS, writing H&P. On-call resident is responsible for adding patient to CORES, updating CORES, and reviewing orders to ensure no errors and that orders are complete.
Psychiatric Consultation
• Follow-ups o AM call: See all CL follow-ups signed out by the CL team. o PM call: See any follow-ups that AM call could not see.
• Answering consult requests from other services: Carry and respond to the on-call pager, which is the pager for psychiatric consults on weekends/holidays.
o Respond to pages within 5 minutes. o Take the consult. Be sure to ask for
▪ Patient’s name ▪ U# (MRN) ▪ Reason for admission ▪ Consult question (clarify the consult question, should be a specific question not
simply ‘the patient has psychiatric history’) ▪ Safety concerns such as SI or HI. If there is any concern about SI/HI/elopement,
then have the team immediately place a 1:1 sitter while you complete the evaluation.
o Instruct the primary team to place a consult order to H Psychiatry Consult/Liaison. o Once this order is placed, the patient will automatically appear on the CL list with a green dot,
indicating a new consult. o Manage expectations: Discuss how soon you will be able to see the patient with the primary
team. If needing to pass the consult to the next resident, discuss this with them.
• New evaluations o See as many new patients as you can. You should balance seeing patients with not working
past your shift. o Urgent consults should be prioritized over non-urgent consults. See Triage below. o Non-urgent consults should be completed, time permitting. o Sign out any pending evaluations to the next resident. o If you do not think a consult is urgent but the primary team is asking you to come
immediately, please call your attending to discuss this.
• Staffing o Staff all follow-up and new consults with your attending. o AM Call: Staff with 5WA attending until 6 PM, then staff with overnight attending accessible
by paging the HMC operator. o PM Call: Staff with overnight attending who should contact you between 8-9 PM. If they do
not, please page through the HMC operator.
• Notes o CL Initial: Put in Service as Psychiatry (the number 12) FIRST, then select type as Consult.
This will autopopulate the CL template. PLEASE DELETE THIS TEMPLATE and use the SmartPhrase .HMCPSYCHCONSULTINITIAL
o CL Progress: continue to use the type Consult, delete the initial CL note and use the SmartPhrase .HMCPSYCHCONSULTPROGRESS. Or, if there was a previous note, you can copy forward by clicking copy on last note.
▪ Epic SmartPhrases: If a SmartPhrase has not been shared with you by the chief resident, go find the smart phrase under the chief resident’s name and add yourself to it. See this video for help:
• Sign-out: Be sure to update CORES for each new and follow-up patient. Verbally sign-out all new
and follow-up patients. PES: PM call only
• Evaluate PES patients under supervision of PES attending.
• See PES Workflows created by Dr. Borghesani and Dr. Reiner from the PES and updated by them.
• Call the PES by 9:00 PM to let them know how many consults need to be seen and the approximate time you will be in the PES. If unable to go to the PES after 11 PM, please call a second time around 11:15 PM.
• 24-hour calls o 24-hour calls mostly occur on Friday nights when the resident has worked in clinic or on-
service during the day. May also occur any weeknight if the 2nd or 3rd back-up resident is called in or no nightfloat resident is scheduled (in which case the weeknight coverage is analogous to weekend PM coverage).
o Residents are guaranteed a 2-hour break to sleep during these call shifts. Residents should work with the PES attending to find a good time to take this break.
o If a resident receives push back about taking the break, please contact the PES chief resident and APD Matt Iles-Shih via email.
Triage of Responsibilities Day call
1. Emergent and urgent cross-cover issues (medical or psychiatric) on 5WA/5WB/5MB units take precedence over all other issues as at times, the on-call resident is the only physician taking care of these patients.
o In general, attendings will handle most daytime cross-cover issues on the units while they are in house. They may ask you to follow up on a lab result, medical issue, etc. If you are extremely busy, you may need to negotiate division of workload.
2. Urgent consults: include safety assessment (SI/HI), capacity to leave AMA, capacity to refuse an emergent/urgent procedure, and acute agitation. Safety assessments should be seen ASAP.
3. Non-urgent consults: include medication questions (not for agitation), general psychiatric evaluations, other less urgent issues.
Night call:
1. Emergent and urgent cross-cover issues (medical or psychiatric) on 5WA/5WB/5MB units take precedence over all other issues as at times, the on-call resident is the only physician taking care of these patients.
2. Urgent consults: include safety assessment (SI/HI), capacity to leave AMA, capacity to refuse an emergent/urgent procedure, and acute agitation. Safety assessments should be seen ASAP.
3. Non-urgent consults: include medication questions (not for agitation), general psychiatric evaluations, other less urgent issues.
4. PES: Call the PES by 9 PM to advise when you will be down. Call again by 11:15 PM.
On-Call Tips
● Respond to pages within 5 minutes. This means you may need to leave a patient interview briefly, which is 100% okay to do.
● Always follow-up pages, even if they seem insignificant to you. They may not be insignificant to the person paging.
● When ordering new PRNs requested by RNs, close the loop by telling RNs the medication has been ordered. Remind them to refresh.
● Your attending is your back-up and wants to hear from you.
● Call you attending for help with triage if unsure. ● If there are consults you are not able to get to during a weekend day, the night resident can
always help out. ● You are not required to see patients with 1:1 sitters or who are involuntarily detained unless it is
psychiatrically necessary.
● Be sure to take breaks, eat, hydrate, and take care of yourself. ● If you have an unprofessional interaction with a consulting team, staff, DCR, admission
authorization person, or anyone else, please debrief with your attending and email one of the chief residents at HMC.
What should I do if I become ill or can’t continue to work during call? If you become ill or for any reason cannot carry on your duties, (i.e. fatigue so you cannot work, family emergency during a call/night float shift) you should:
● Seek medical attention, if necessary, at Employee Health or the ER.
● If you are being trained on training call, let the training resident know. They will take over your call. Give them the on-call pager
● If you are the R3/R4 trainer, call in the 2nd backup resident (not the risk resident who is a R2 and cannot do training calls) immediately to take over training.
● If you are on a solo call, notify the 1st backup resident immediately.
● All back-up residents are listed on SpinFusion https://www.spinfusion.com/SpinSchedules/login. Group: UWPsych. Individual pager numbers can be found on MedHub. Look under ‘Resources/Documents.’ Click ‘Psychiatry Residents Personal Contacts List.’
● Wait for the backup resident to arrive; backup residents are allowed up to one hour to arrive at the hospital. Hand off the on-call pager and sign-out.
● Try to arrange for a ride home, if possible. Harborview’s Parking Office operates a sick employee ride home service, which you can access by calling 744-3193.
• A medical student (or two) may be on call with you at HMC. Their weekend call shift times are 8am to 4pm and 4pm to 11pm. Weeknight shift times are from when the student finishes his/her day work until 10pm.
• The student is responsible to find you at the start of his/her shift.
• Teaching opportunities: o PES evaluations o Participating in CL interviews o Discussing your job as an on-call resident
• Students are not allowed to write notes cross-cover or consult notes while on-call. Direct attending supervision is required to fully bill for these notes.
• Please contact the inpatient chief resident or Dr. Paul Borghesani with any difficulties/problems/questions you have about students while on call.
On call amenities, where to eat, sleep and get scrubs
● Food is available at o HMC cafeteria: hours are variable and can be unpredictable o Vending machines are located near the main patient entrance to the ER. o While there is also food available in the PES, this is primarily for patients. You should
check with the PES nurse before eating or drinking anything in the PES refrigerator or cupboards.
● Sleeping o Call room 5MB sky bridge, RM 502; code 6013, 6013 o Please keep in mind that the expectation for the Night Float Resident is that s/he will
sleep during the day and stay up at night for call. However, you should still take breaks as needed.
● Scrubs o 1CT 91: door code 911911 o 2WH 91: door code 206206
● Lactation Rooms: o Call room often can be used o To find lactation rooms @ UW and HMC, go to
https://hr.uw.edu/benefits/care/parenting/lactation-stations/ - there, you can contact the organizers and find out how to sign-up for the particular station you are interested in and learn about which rooms contain refrigeration, etc….
Where is the CL office and chief resident offices?
• Both located in the 5 East Clinic area, 5EC 29 through 5EC 38
• Directions from the 5th floor resident work room: o Make a right out of the resident work room walking toward Maleng. After about 30 feet
the center tower is located on your right, walk through the center tower. Walk past the center tower elevators and walk through large double doors into the 5 east clinic. Continue to walk through the 5 east clinic until you get to the east clinic elevators. To the left of the elevators is a door with a glass window. Code 111333.
Attending Coverage
● The PES attending will supervise your work in the PES as well as the occasional consult in the medical side of the ED.
● The on-call attending backs you up on ALL OTHER consult issues and floor matters and will co-sign your consult and inpatient notes. They are your co-signer for all CL initial and follow-up notes, cross-cover notes (progress, significant event, fall notes), and H&Ps. Any time Epic asks you to put in a name for a ‘procedure,’ use the on-call attending.
● Hours o Weekdays: On-call attending overnight shift starts at 5 PM – 8 AM o Weekend/holiday day: On-call attending is 5WA attending 8 AM – 6 PM o Weekend/holiday night: On-call attending overnight shift is 6 PM – 8 AM
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You MUST contact the On-Call Attending for:
● Every new consult
● Clearance for unplanned discharges, whether AMA or not ● Any clinical decision-making related to suicidal/homicidal ideation, i.e. removal of 1:1 sitter
● Any physical assault and any sexual activity on the unit ● Any attempted suicide on the unit
● Serious conflict with other service or staff regarding delivery of care to patient ● Patient transfer from psychiatry to Med/surg/ICU
● If you receive a page indicating an internal or external disaster (see “disaster preparedness”) Highly recommend to contact the on call attending for:
• Assistance with triaging consults o PM and nightfloat: Always check-in with your attending before deciding to not see a
consult, triaging this consult to the next day. o AM call
▪ Check in with the 5WA attending in the morning to advise them of how many new and follow-up consults you have. Discuss triage with your attending.
▪ Continue to discuss triage throughout the day. ▪ If the number of urgent new consults exceeds the amount of patients the resident
could practically see during the remainder of their shift, the 5WA attending should contact the 5MB attending to help see the urgent consults.
● Any other issue for which you would like attending supervision / consultation (seriously, this is the one thing that junior residents don’t tend to do enough- this is your education!)
When to call IN the attending: When any of the following situations arise, you must absolutely call the attending to discuss the case. In some of these situations, you and the attending may decide that it is most appropriate for them to come to the hospital to assist you.
● Patient death ● Serious assault on unit
● Internal or external disaster
***If you have a scenario where you called in your attending (or thought hard about calling them in but decided not to), please email the chief resident with the email title “QI Confidential” and notify her/him of the incident. Who is my on-call attending? Weekday evenings (5-8 PM) short call
● Your on-call attending is assigned by the department for each call night and covers both UW and HMC.
● The on-all attending does not page the short call resident but are aware that their shift starts at 5 pm. Call the operator and ask to have the on-call psychiatry attending paged. Please let the chief resident know if you had trouble contacting the attending.
Nights (8 PM – 8 AM)
● Your on-call attending is assigned by the department for each call night and covers both UW and HMC. The on-call attending will page the HMC nightfloat resident between 8-9pm.
Weekend/Holiday Days (8 AM – 6 PM)
● The on-call attending covering consults on weekends is the attending covering 5WA until 6 PM. ● After 6 PM, page the On-call psychiatry attending through the operator.
If you have trouble figuring out who your attending is: 1. The operator at HMC will always have the correct on-call attending. 2. Check the email sent to you from Jes Olson about your call shift that lists the attendings
and their pager numbers.
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Occasionally, the attendings may shuffle duties (e.g. the 5WB attending take overnight calls), in which case you should be notified. If you cannot reach the on-call attending:
● If the on-call attending cannot be reached by pager, the resident should ask the HMC operator to call the attending at home (they should have the home or cell phone number).
● If the attending still does not respond, residents should then use the PES attending for supervision
● Notify the HMC inpatient chief resident via email if you are unable to reach your on-call attending.
● If you cannot reach the on-call attending or the PES attending (this should be very rare), use the HMC Operator or the numbers below to page the following attendings in this specific order. Page first and if no answer then use the cell phone number. If they do not answer, then use the home number. If they still do not answer, go down to the next attending on the list.
1. Mark Snowden, MD HMC Chief of Psychiatry o Pager: 663-2336, cell: 206-388-8311, home: 206-368-8027
2. Paul Borghesani, MD PhD, PES Medical Director o Pager: 340-3082, cell 206-380-2563
3. J Veitengruber, MD, Inpatient Psychiatry Medical Director o Cell: 206-335-7592
4. Amelia Dubovsky, MD, HMC Inpatient and CL APD o Cell: 917-912-2811
What if there is no PES Attending while I’m on call?
1. First, remember that you can always run things by the On-Call Attending, and should notify them that there is no PES attending available – that way they are primed to expect more than the usual number of pages!
2. Second, remember that the PES nursing staff, social workers, and ARNPs have a vast amount of experience – so use their expertise.
3. When there is no PES Attending, you may need to see and evaluate patients that were seen by the ARNP or the Social Worker.
If you are a R1, it is considered a violation of ACGME rules for you to be in-house alone. In the emergent event that a PES attending is unavailable, backup residents will provide R1s with in-house supervision.
• 1st back up (risk resident) replaces the R1 on call, rather than provide supervision
• If risk hasn’t been trained at Harborview or is unavailable, 2nd back up (an R3) comes in and the shift functions like a training call.
• The back-up resident will be given a call break in the following call cycle. Patient Movements INPATIENT DISCHARGE PROCESS
• History Tab: Fill out all History tab (Access via Problems -> History). Please use Social documentation (History tab -> social documentation) to enter in the patient’s Psych history as that’s what our template pulls in.
• See this video https://youtu.be/5t2i09HGnTQ at 26:42 minutes.
• Medical students can help with filling in and gathering more history.
• Be sure to document accurate information. Do not put inaccurate information in order to fill out the boxes. Not every box will be filled out for each patient!
Discharge Medication Reconciliation: Contact your pharmacist. Currently, this is a joint process due to recent Epic transition.
Discharge Workflow: Discharge Navigator Discharge Summary: Service - Psychiatry. Note type - Discharge Summary.
• Follow above Discharge Workflow. Highly recommended to do discharge med rec and problem list reconciliation prior to starting Discharge Summary.
• For now, the incorrect discharge template autopopulates. Select all (CTRL/command +A) and delete. Use SmartPhrase HMCPSYCHDISCHARGESUMMARY.
• Discharge Medications: Type in an indication for each medication.
• To change Interim Summary to Discharge Summary: o Find Interim Summary and click on note. o Click ‘copy’ at the top of the note. o Change Note Type to Discharge Summary. Double-check that service remains Psychiatry. o Edit and update. (make sure to updates sections such as discharge mental status exams, discharge behaviour rating scale, discharge date, ITA status, etc) o TIP: click the Refresh icon in the note if you change discharge medications, problem list, hospital course, history, etc.
Hospital Course: Type the hospital course in Hospital Course tab: access via Problems -> Hospital Course.
• TIP: you may need to scroll up to find the hospital course tab.
• The hospital course you write will be automatically added to the interim/discharge summary.
• You (or your student) can work on the hospital course throughout your time on the team.
• Hospital Course contents: o 1-2 paragraphs about patient’s initial presentation, diagnosis, treatment with
medications and psychotherapy techniques, and improvement o Safety assessment: suicide risk, risk factors and protective factors o Medical issues, including chronic conditions and medications that were continued
from home; if no medical issues, state that patient had stable VS throughout and had no signs of infection/other medical conditions
o Note: if patient is transferred from a medical service, please add in a summary their medical hospital course found in the medical discharge summary
Sample Hospital Course: Mr. X presented with the following symptoms of major depressive disorder: low mood, intermittent suicidal ideation with no plan, anhedonia, shame, poor appetite, and poor concentration. He reported that these symptoms were cyclical, coming and going for weeks at a time since August 2017. He had been without his medications for approximately 2 months prior to admission. Given his past impulsive suicide attempts, he was admitted to inpatient psychiatry for safety and stabilization. He described his suicidal ideation as "intrusive" but after discussing OCD symptoms with the patient, it was felt that he did not meet criteria for OCD. He reported a high level of anxiety. He had several recent stressors that were contributing to his low mood and anxiety: new job, recently being told that he does not meet criteria for autism spectrum disorder (he believed that he had Asperger's syndrome for years), and pressure from family to obtain a full-time job. He denied panic symptoms, past trauma, past mania, and psychotic symptoms. He adjusted well to the unit and participated in all groups without incident. Mr. X had taken citalopram since at least 2011; he overdosed on citalopram in 2015 and had seemingly continued on citalopram since (with the exception of the recent drug holiday). We offered a change in antidepressant to the Mr. X who was very amenable to this. He was started on venlafaxine, which was titrated to 150 mg without any side effects. The low-dose mirtazapine was stopped as the patient had noted no effects from this medication. We also wished to simplify his medication regimen and reduce polypharmacy. In the future, if he needs help with sleep or augmentation of venlafaxine, mirtazapine could be started again. With a combination of medication changes, group psychotherapy, and participation in the therapeutic milieu, the patient’s suicidal ideation remitted and his mood improved. He felt safe for discharge after one
week of inpatient hospitalization. On the day of discharge, Mr. X denied suicidal ideation/intent/plan and was future-oriented with plans to seek a job and see his therapist. Overall, Mr. X has a moderately increased risk of suicide compared with the general population. His risk factors include male gender, past suicide attempts, and his psychiatric diagnoses. His elevated risk is ameliorated by his protective factors of future-orientation, responsibility to his parents, engagement in mental health treatment, and willingness to follow his crisis plan. Mr. X had no medical issues while hospitalized. His vital signs remained stable throughout the hospitalization. HMC PSYCHIATRY UNIT TO UNIT TRANSFERS
• Place transfer order.
• Give warm hand-off to receiving team.
• Sending team writes Interim Summary: In Notes tab, open New Note. Service – Psychiatry. Note type – Interim Summary. Use SmartPhrase HMCPSYCHDISCHARGESUMMARY to pull up template.
o Copy and paste HPI from H&P. Make sure History and Hospital Course autopopulate. o Be sure to bring in relevant labs – go to Results tabs and select labs you want. Right-click and click copy. Then paste into Interim Summary.
Special Considerations: Transfers from 5MB to 5WB
• Sending team o Review medication orders. Does the patient have appropriate PRNs and a compel
order? o If no compel and on ITA hold, be sure to document why in progress note and in
CORES. o Write transfer order and interim summary. o Contact receiving team's resident or attending to give a warm hand-off, specifically
discussing agitation management and compelled medications. What has worked well for the patient?
• Receiving team o Receive a warm hand-off from sending team. If no one has contacted you, page them
before 5 PM. o Review PRN agitation medication orders.
▪ Keep agitation PRNs such as benzodiazepines or antipsychotics for at least 3 days. Adjustment to 5WB can be difficult for patients transferring from 5MB. Even if the patient has not required medication for agitation recently, they may require these in the first few days after transfer due to the destabilization of transferring units. Discuss with your attending prior to discontinuing PRNs.
▪ If the patient does not have any PRNs for agitation, be sure to add some prior to sign-out. Ask the sending team what has worked for the patient. If you cannot reach the sending team, do your best through chart review. As always, discuss with your attending.
o Review compel orders. If patient is scheduled for antipsychotic and on ITA hold, they should either have a compel medication or a well-documented reason why a compel is not indicated. This should be documented by the sending team in progress notes and CORES.
o Short call and night float considerations (for transfers after hours) o Escalating behavior/agitation
▪ If RN has paged regarding need for PRN agitation medication, you must assess the patient in person. Be sure to write a brief note.
▪ Do not be afraid to prescribe antipsychotics or benzodiazepines for agitation. If unsure which option is best, discuss with the Doc of the Day (until 5 PM) or the on-call attending.
o Compel Orders: If the patient has refused scheduled oral antipsychotic and no compel medication has been ordered:
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▪ Chart review: Can you find a reason that a compel has not been ordered? If there is a good reason, you should discuss with the Doc of the Day (until 5 PM) or the on-call attending if the documented reason is appropriate. Communicate this reason with nursing staff.
▪ Assess patient. Are they psychotic? Are they agitated? If yes to either or both, patient may benefit from a compelled medication. Again, discuss with your attending.
▪ Order compel: Order an intramuscular version of an antipsychotic as PRN Compel. If unsure the dosing or antipsychotic to order, discuss with your attending.
▪ Deferring the decision to order a compel to the patient's daytime team is inappropriate and poor patient care. Not treating the patient can be dangerous for the patient and providers.
TRANSFERS TO/FROM HMC INPATIENT PSYCHIATRY Transfers from HMC Inpatient Psychiatry to HMC Med/Surg: See Inpatient to Med/Surg
• After receiving acceptance from HMC hospitalist or surgery team for transfer, follow above link to complete DC-readmit process.
• Psychiatry resident (inpatient, short call, on-call resident) responsibilities: o Medication reconciliations o DC Summary with recommendations for psychiatric care (including need for 1:1 monitor) o Verbal hand-off to receiving physician o Verbal hand-off to CL team (if patient requires ongoing psychiatric care)
• Receiving team’s responsibilities: Placing admit orders Transfers from HMC CL (Med/Surg) to Psychiatry: See CL to Inpatient and this video https://youtu.be/uEM0prOp3Kg
• Once a bed has become available and the psychiatry screener or weekend social worker has approved the transfer, follow the above links to complete DC-readmit process.
• Psychiatry CL or on-call resident responsibilities: o Request primary team to complete order/med reconciliation through DC-readmit tab o Request primary team to write DC summary o Place admission orders o Give verbal hand-off to inpatient psychiatry resident (if day time hours) o Be sure a CL progress note has been written that day
• Psychiatry Inpatient, short call, or on-call resident responsibilities: o Review orders for accuracy o Add patient to appropriate team list and update CORES sign-out o Double check that a psychiatry note had been written for the day of transfer. If no note
has been written, write a H&P that day. If a CL progress note has been written, the H&P can be deferred to the next day.
TRANSFERS FROM OSH TO HMC INPATIENT Residents do not facilitate direct admissions. If you receive a call from another hospital requesting admission to HMC: advise them “I am not authorized to accept direct admissions.” They should be advised to contact the HMC Psychiatry screening nurse. (Screening nurse pager: 989-4845). Transfers from UWML ED or UW-NWH ED to HMC Inpatient Psychiatry: See UW ED or NWH ED to HMC IP Transfer Transfers from UWML CL or UW-NWH CL to HMC Inpatient Psychiatry: See UW CL or NWH CL to HMC IP Transfer
• Sending CL team (at UWML or UW-NW) is responsible for liaisoning with the primary team or ED. o Primary team and ED need to reconcile all orders.
▪ For admitted patients, orders are reconciled through the DC-readmit tab. ▪ For ED patients, orders are reconciled through the discharge tab.
o Primary team should write a DC summary. ED team should have an up-to-date ED note completed.
• Sending CL team (at UWML or UW-NW) writes the admission orders for the patient. The sending team should write orders as they know the patient and patients’ case best.
• Sending CL team (at UWML or UW-NW) should write a CL progress note (initial note if one has not been completed) on day of transfer.
• Send CL team (at UWML or UW-NW) should call the receiving HMC resident, attending, short call resident, or on-call resident and give a verbal handoff.
• Receiving resident at HMC should o Receive a verbal handoff from the UWML or UW-NW team. o Review orders for accuracy o Add patient to appropriate team list and update CORES sign-out o Assess the patient, perform ROS and full physical exam o Write H&P
NWH Inpatient Psychiatry to HMC Inpatient Psychiatry
• Sending IP team (at NWH) uses DC-readmit tab to reconcile all orders AND writes the admission orders. See UW CL or NWH CL to HMC IP Transfer (similar process but the psychiatry team is the primary team).
o The sending team should write orders as they know patient’s case best
• Sending IP team (at NWH) writes a DC Summary.
• Sending IP team (at NWH) calls the receiving HMC resident, attending, short call resident, or on-call resident and give a verbal handoff.
Transfers from hospitals outside of UW Medicine: All patients must go through the PES. TRANSFERS FROM HMC to OSH HMC CL to OSH
• Social work or on-call resident screens patient with OSH. If a bed is available for patient at OSH, patient will be discharged from HMC. The primary team’s SW or unit PSS can help arrange transport.
• Primary team responsible for DC orders, med rec, DC summary through regular discharge tab.
• CL resident or on-call resident responsible for writing a CL progress note with up-to-date psychiatric recommendations and guiding the primary team with their DC med rec for psychotropic medications.
HMC CL to NWH IP Psychiatry
• Sending CL team (at HMC) is responsible for liaisoning with the primary team. o Primary team must reconcile all orders through the DC-readmit tab. o Primary team should write a DC summary.
• Sending CL team (HMC) writes the admission orders for the patient in the DC-readmit tab. o See UW CL or NWH CL to HMC IP Transfer (similar process but in reverse). o The sending team should write orders as they know the patient and patients’ case best
• Sending CL team (HMC) writes a CL progress note (initial note if one has not been completed) on day of transfer.
• Sending CL team (HMC) calls the receiving UWML/NW resident, attending, short call resident, or on-call resident and give a verbal handoff.
HMC Inpatient Psychiatry to NWH Inpatient Psychiatry
• Sending IP team (at HMC) uses DC-readmit tab to reconcile all orders AND writes the admission orders. See UW CL or NWH CL to HMC IP Transfer (similar process but the psychiatry team is the primary team).
o The sending team should write orders as they know the patient and patients’ case best
• Sending IP team (at HMC) writes a DC Summary.
• Sending IP team (at HMC) calls the receiving UWML/NW resident, attending, short call resident, or on-call resident and give a verbal handoff.
HMC PES to Seattle VA
• Verify VA eligibility through the VA Administrator On Duty (AOD): 762-1010.
• Call the resident on-call at the VA (either directly or via VA paging operator: 762-1010) to check bed availability and present the patient.
• If the VA on-call resident agrees to accept the patient in transfer:
• Complete and copy the following forms: o ED and PES notes o Physical Exam (or make sure the electronic version prints with the note)
• Complete and have the patient sign the Consent for Patient Transfer
• Put the following forms into the AMR Envelope: o Copy of ED/PES notes o Copy of Physical Exam o Yellow Copy of Consent for Patient Transfer
• Put the AMR Envelope on the back desk (by the stamping machine) and call AMR (444-4444) to take the patient to the VA ER.
• Be SURE and tell the patient you cannot guarantee that they will be admitted: the VA Resident may decide not to admit them.
• Any staff member can call a rapid response; they are most often initiated by nursing staff.
• A RR triggers a stat nurse to come to the unit.
• Reasons RR is called: o Any intuitive sense something is wrong with patient. o Acute change in:
▪ Mental status ▪ Respiratory Status ▪ CV status
• HR <55 or >120
• SBP <90 or >170
• Decreasein HCT by 6 points/24 hrs o New onset chest pain, agitation, restlessness o Acute change in temperature <35C or >39.5C
• Resident should go immediately to patient’s bedside.
• Call medicine consults if clinically indicated. AMA Discharges or Requests to Leave
● Check CORES and progress notes to see if there is a contingency plan in place for AMA requests
● Discuss case with nursing staff, charge nurse ● Evaluate patient at bedside, determine if redirection possible
● See if primary team left an affidavit
● Assess patient for DCR referral. Discuss with on call attending to determine if you should proceed with referral.
● If patient not detained by DCRs, call attending first before releasing, could consider re-referral if very concerned.
● ALWAYS call attending before discharging a patient
● If you and the attending decide to discharge the patient AMA, we do not provide discharge medications. The most common exception to this would be if there is a risk of withdrawal from meds (i.e. benzos). If you decide that it is crucial to write for discharge meds, make sure that you write a short prescription (<1 week supply). Tell patient to either f/u with their current outpatient provider or call crisis line/ go to ER if needed.
● Document this encounter in a progress note, explaining your medical reasoning about discharge.
● Complete discharge summary.
Vulnerable Patients Safety The policy identifies geriatric (age 60 and older) female patients with dementia to be in a high-risk vulnerable category that require a specific placement guideline.
● If a patient needs a psychiatric admission, CL team or PES will attempt to place patient in an appropriate inpatient geriatric unit (e.g. NWH) If no beds are available, the patient should be screened for the 5WA or 5WB (rather than 5MB).
● If the patient does not meet criteria for admission to the West units, the patient should be placed on boarding status in the PES or medical unit.
● If for behavioral reasons the patient needs to be admitted to 5MB, the patient needs a a one-to-one monitor until transfer to the West units is clinically appropriate.
● Please notify the appropriate HMC chief resident who can notify the medical director of the services and the HMC Chief of Psychiatry.
ASSAULTS HMC ASSAULT POLICY Sexual Activity/Assault on the Ward Procedure All allegations of sexual abuse/assault by patients are taken seriously. Any sexual activity on the inpatient psychiatry ward may be considered "non-consensual" as our patients may not have capacity to consent
when hospitalized. Therefore, we recommend following this procedure whenever any sexual activity occurs on the unit:
● Nursing staff will either contact the attending or the resident to alert them of the occurrence or the allegation
● The resident should immediately evaluate the patient to assess need for urgent medical care, including SANE, and then contact their attending. Psychiatry residents are NOT expected to perform a gynecologic exam.
● If patient needs a SANE for sexual assault, call the ED social worker through the operator who can contact the SANE nurse.
● If the patient does not have capacity and has a surrogate decision-maker OR requests to have family contacted—the resident should discuss with their attending who is the most appropriate person to alert the surrogate/family.
● The attending should coordinate with the Administrator on Call (the AOC) and receive further instructions from them. (Feel free to remind your attending of this, particularly if they are an outpatient attending.)
● The resident will then complete a cross-cover note to document the incident and to document what interventions were taken afterwards (ie: SANE nurse has been contacted, etc)
● If this occurs while you are on call, PLEASE EMAIL the chief resident with the email title “QI Confidential” and alert them of the incident.
Physical Assault ON PATIENT Procedure All allegations of physical assault by patients are taken seriously. We recommend following this procedure whenever an assault occurs on the unit:
● Nursing staff will either contact the attending or the resident to alert them of the occurrence or the allegation.
● The resident should immediately evaluate both patients (victim and perpetrator) to assess need for urgent medical care and then contact attending.
● If the patient does not have capacity and has a surrogate decision-maker OR requests to have family contacted—the resident should discuss with the attending who is the most appropriate person to alert the surrogate/family. Typically, on-call attendings should inform families.
● The attending should coordinate with the charge RN to determine if the Administrator on Call (the AOC) needs to be contacted. (Feel free to remind your attending of this, particularly if they are an outpatient attending.)
● The resident will then complete cross-cover notes on both patients to document the incident and to document what interventions were taken afterwards.
● If this occurs while you are on call, PLEASE EMAIL the chief resident with the email title “QI Confidential” and alert them of the incident.
● Note: the victim may decide to press charges – if this occurs and the police arrest the patient and take them to jail, please see below on steps when a patient discharges to jail.
Physical Assault ON RESIDENT Procedure Staff safety is a top priority for your chief, program director, and department leaders. If you are assaulted by a patient, please immediately:
● Call/page your team’s attending or the attending on call immediately to discuss, plan, debrief, and receive emotional support
o Please note, you or your attending can page Dr. Mark Snowden through the operator at any time to clarify any procedures.
● Seek any emergent/urgent medical care needs that may be required – please have a very low threshold for seeking medical care.
o Go to Employee Health M-F 0630-1630, Sat 0700-1200 o Go to the ED if Employee Health not open or serious injury.
● Inform the HMC chief resident – please page or text – their role is to not only help support you, but also notify Mark Snowden, program director, associate HMC program director.
● Coverage o On service: your attending will take over patient care responsibilities. o On short call, please let chief know ASAP to find coverage.
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o On call: Activate the back-up resident to relieve yourself of patient care duties (the back-up resident will assume next care steps for the patient who assaulted you, as well).
● Other Steps: o Submit a Patient Safety Notification Incident (PSN) by double-clicking the PSN
icon on your desktop. This helps trigger QI processes in the hospital – while it is great if you can provide documentation, other staff can actually do this step for you. A QI process will happen regardless of the PSN - the PSN functions simply as back-up documentation.
o Press charges against the patient. ▪ Please talk with your attending and chief resident. The main consideration is
– did the patient do this volitionally?
▪ Procedure: call 911 and report an assault. Best to do this from the hospital as the police will come and interview you and other staff to take statements. If the police arrest the patient, please see below on steps when a patient discharges to jail.
When this happens, other residents are present or find out. We want to do our very best to support you and other residents while respecting your privacy. We want to support you in accessing any medical and emotional supports. We recommend you seek supervision and support with the attending you were working with at the time of the assault, but below are other supports available to you:
● Harborview Crisis Response Team: this is an interdisciplinary team consisting of many different types of staff members that supports staff when they experience trauma. This team consists of:
● Peer-to-peer support – the chief can help connect you to residents or fellows who have had similar experiences if this would be useful
● T-group Discharge to Jail Patient discharges to jail can be emotionally and ethically challenging. Please always talk to your attendings, chiefs, and program director to access supervision and support around this issue.
● Victims of assaults have the right to pursue legal action through the criminal court system, meaning they can press charges against the person who assaulted them. One does not have to press charges. This is a personal decision.
● When charges are pressed, the police will guide this person through the process. It is best to press charges from the hospital but if desired you can go home. The police may arrest the person who committed the assault and take them to King County Jail.
● Discharge to Jail Steps: o Notify the on-call attending as this is categorized as an “irregular” discharge. The attending
should call the administrator on duty (AOD) for any “risk-management” or legal questions and call any family members to inform them of the situation.
o Briefly see the patient (with staff for safety) to complete a mental status exam and for the purposes of completing a cross-cover note that details what happened.
o Complete discharge medication list – patient should not receive ANY prescribed meds if going to jail. Please ‘continue but not prescribe’ medications during med reconciliation for all meds the patient should continue.
o Complete discharge summary and place discharge order.
o Fax to discharge summary to King County Jail (nursing station may be able to help with this) to help ensure continuity of care and that patient continues to get their meds. KCJ mental health team really appreciates this!! Main point of this summary is to clearly document diagnosis and DC med list.
Patient Elopement
● Contact the on-call attending to inform them of the elopement. Typically, on-call attendings should inform families.
● Check whether the patient is voluntary or involuntary. o If the patient is involuntary:
▪ Call the Crisis Clinic to inform them of elopement.
▪ Call 911 to inform the SPD; inform HMC security – note that nursing may have already done this; ask them first.
▪ Check whether there is a duty to warn and take appropriate steps to warn target. o If the patient is voluntary:
▪ Look at recent notes and CORES to assess level of risk – consider contacting 911 if the patient is considered high risk.
● Write a brief cross-cover note indicating the steps you took. Primary team will be responsible for the discharge summary.
● Of note: If a patient leaves without permission, we can hold the bed for 4 hours, after that time, the bed will be released. Thus, if a patient returns after four hours, they would need to be redirected to the PES.
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HMC CONSULT-LIAISON PSYCHIATRY DETAILS Speaking to other services, being a liaison
● Doing C/L work often means speaking/working/laughing with physicians and nurses from other services. It is important to remember when doing this kind of work that we are providing a service to other physicians, much as they provide a service to us when we call them for consults. So put on your best customer service hat and play nice in the sandbox. Provide empathy, validation to the staff and providers.
● Often, however, other services want things that we cannot give them. If this is the case, try to determine the primary team’s perceived priority of their request to make sure it is in keeping with your perception of when you can meet their needs.
● If you cannot see/admit/diagnose a patient as soon as a primary service would like you to be able to for whatever reason, it makes the best sense to be honest and discuss with them your thoughts. Sometimes other services think things are more or less important than we do. Coming to mutual understanding of the needs of the other service, what we can provide, and what is in the best needs of the patient, can end lots of potential conflicts before they start.
● When in doubt, discuss any management issues you may have with your on-call attending. ● If you are called by a team or a nurse about doing a “two physician override:” The two physician
override is an idea that if two doctors think a patient needs something, they can override the patient’s wishes and implement the treatment, surgery, etc. It does not exist in our practice (at least in the state of WA). Inform the team that a two physician override cannot be done, but that you can evaluate the patient for decisional capacity, then approach the case as you would for a standard capacity evaluation.
Completing a consultation
● During your phone call with the requestor, get an understanding of the reason for the consult. If this is a weeknight consult, you may need to triage the issue until the following day. Let the requestor know when you or someone else from Psychiatry will be able to see the patient. Keep in mind that patients with suicidal ideation or following a suicide attempt should be seen within 90 minutes of the consult being placed.
● Given the high volume of new consults during the day time, it might be reasonable to see a consult over night, even if it is not urgent. This decision should be made based on the work load in the PES.
● Go to the ward, review the chart for 5-10 minutes, and ask nurses for their observations. You might also want to speak to some collateral sources to see if they drop any clues.
● Your patient interview should be no longer than 30-45 minutes. Focus on: HPI; past psychiatric history; current medications; social situation; drugs & alcohol; and the mental status examination.
● Write a succinct note – Using the C/L Initial Consult form for new consults or the C/L Progress note for follow-ups.
● Recommendations should be numbered, worded explicitly, and listed by priority o Things of particular note are dosages and titrations of meds, and whether restraints are
needed (or can be discontinued). ● Do NOT place orders on CL patients – we make recommendations to the primary team, which
is responsible for entering orders (this helps to delineate roles and ensures no duplicate orders or a tragedy of the commons phenomenon.)
● Page the primary team’s resident and briefly review the case with them and place the patient in WKND CORES subteam.
● Transfers to Inpt Psychiatry are possible on the weekend; transfers at night are not, absent exigent circumstances (review with your attending). Review bed availability with the PES Social Workers & the inpatient charge nurses.
● For the voluntary transfers, authorization is needed. Call the PES Social Workers (x42649) who are happy to help us coordinate authorizations to point of providing the clinical information to the clinician from the authorizing agency. The Social Worker would expect us to provide the clinical information directly to the authorizer once they do the preliminary assessment of insurance and
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initial phone calls to reach the authorizer. Be sure to document details of authorization in your note once you’ve obtained it.
● Call the on-call Attending after each consult, no matter how trivial it may seem, and make sure you put the On-Call Attending as the co-signer.
● Prior to any transfers to the Psychiatry Inpatient Unit, an interim or a discharge summary by the primary team must be completed with appropriate recommendations for any ongoing med/surg issues. This CAN be waived for a compelling reason (I can’t think of any right now), but the referring team should explain what the reason is. If they feel the patient is simply unmanageable, you can suggest ways Mr. Difficult be kept safe (medications, sitter) while the team finishes its summary, or if this is not practical, you can quiz them on the medical issues and get them to provide you with a verbal plan to manage any foreseeable problems.
Med/Surg Pt. is requesting to leave AMA
1. Patient is demanding to leave AMA defined as, patient has asked two times or more and is not redirectable, or tries to leave.
a. If redirectable then please document that the patient is willing to voluntarily stay in the hospital
2. Restraints in patients attempting to leave AMA: In many situations, if a patient is in restraints to keep them from eloping from the hospital, they will need to be referred to DCR for evaluation. This is determined by whether or not they have capacity and whether or not they are delirious:
i. If patient does not have capacity: 1. And is delirious: We can hold them without detaining them while we work
to restore their capacity. 2. And is not delirious: Need to refer to DCRs for evaluation
ii. If patient does have capacity: Can only use restraints if you are referring them to DCRs for involuntary detainment otherwise they will need to be release
iii. Okay to have patient in restraints without referring them, if they are at risk of eloping the hospital before you have an opportunity to complete evaluation.
3. Medical restraints: Restraints that are placed clearly for medical reasons (i.e. not behavioral issues such as patient attempting to elope) include but not limited to falls or pulling out their IV lines or other lines. The rationale for restraints must be clearly documented.
4. Additional information regarding when to refer or how to parse decisional capacity in decision algorithm in the Appendix, or in the HMC informed consent policy guide here (links to our intranet)
Consult patients located in the ED When no beds are available on medical or surgical units, some patients who are admitted to medical/surgical services (as indicated by admit orders) remain physically located in the ED ("boarded"). If psychiatry is paged about patients in the ED for whom admit orders to a medical/surgical team are placed, this patient should be seen by the consult service. If admit orders are not placed or there is a question of whether the patient will or will not be admitted to the medical/surgical service, then the PES service is responsible for evaluating the patient. If paged about a patient who is not officially admitted to the hospital, please call the PES attending to add the patient to the PES list. After Hours transfers from HMC CL/Med Surg to Inpatient Psychiatry After Hours, Evenings, and Weekends On-call Resident coordinates transfers from HMC inpatient medical units to inpatient psychiatry (at HMC & outside facilities.) The PES social worker (744-2649) is available 24/7 and the inpatient psychiatric social worker is available Saturdays 8:00AM-4:30PM to consult on specific cases (pgr: 680-8737). This work does not supersede the resident’s responsibility to triage and prioritize safety issues on the floor and CL service. How to Transfer a Voluntary Patient:
o Private insurance & Managed Medicare: programs limit coverage to “in-network” facilities. Check the “cheat sheet” in the PES for further information about specific insurance carriers.
o For patients on Medicaid or who are uninsured: determine the county of residence. Medicaid and uninsured patients are pre-authorized for voluntary inpatient psychiatric admission.
o Veterans: can be referred to the VA. See transfers to VA in patient movement section.
● Find an appropriate bed: o Determine if the patient needs to stay at HMC due to medical acuity o Check bed status at HMC by calling the charges nurses on 5MB, 5WB, 5WA. o Call Facility: Fairfax, Overlake, Swedish Ballard, Northwest, Cascade, Multicare
Auburn. o Check the patient placement guidelines for what medical conditions are acceptable
for each facility. For example, Fairfax is not able to do wound care. o Go to PES to find these numbers.
● If there is an available bed, provide a brief clinical description, and fax a clinical packet (demographic sheet, H&P/admit note, most recent MD notes, labs, OT/PT note or other consult notes if present). HMC and UWMC have access to Orca and no clinical packet is necessary.
● Referral Outcome: The screener will review and call back with an acceptance or denial. If you don’t hear back and are going off shift, call the screener to provide a new contact name/number.
● If accepted: o Find out the name of the accepting provider (physician, PA, ARNP) and the number
for the RN to RN report. o Ask what time the facility can accept the patient. o Call the insurance company or the county authorization line for pre-authorization.
Ask the PES social worker if you are unsure who to call. o Once you have gotten authorization, be sure to document the details in your note o Contact PES social worker or Saturday psychiatry SW for help with AMR/transfer.
● If denied, continue to look for a bed.
Involuntary Patients: ● Check insurance coverage:
o Private insurance & Managed Medicare restrict psychiatric admissions to “in network” or “preferred” facilities.
● Determine if patient should stay at HMC due to medical acuity.
● Call the King County Patient Placement Coordinator (PPC) to locate open ITA beds (206-204-0370.)
● Make referral by calling the facility, then fax clinical information (demographic sheet, H&P/admit note, most recent MD notes, labs, RN notes, OT/PT notes or other consult notes if present).
● If accepted: o Review ITA paperwork:
▪ If on a 120 hour hold, make sure the IT-10 (Custody Authorization form) has the accepting facility checked. If not, call the DCR for a new IT-10.
▪ If on a 14 day or 90/180 day hold, check court order to make sure the accepting facility is listed.
▪ If it is not listed, it must be amended by the ITA court (during normal court, M-F).
o Obtain contact info: name of the accepting provider & phone # for RN-to-RN report. Ask outside facility for preferred ETA.
o Insurance authorization: required for private insurance (document in your note). o Contact Social Worker Contact PES social worker or Saturday psychiatry SW for help
with AMR/transfer. o Notify PPC (206-204-0370) that patient has been accepted at the outside facility.
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● If denied: o Document the reason for denial. o Call PPC, ask if there is an open bed at a different facility.
Psychiatric Emergency Services The majority of your time while on night float/night call will be spent evaluating patients in the PES. The following section details information you may need while in the PES. For more details (i.e. admission procedures, referring patients for involuntary detention, etc…), see other sections and appendices as needed. This PES Workflow document contains important logistics for navigating PES Evaluations & Documentation in Epic: PES Workflow Initial Meet & Greet:
1. All patients must be at least superficially evaluated by a provider (MD, mid-level or social worker) within 30 minutes of arrival. This is to avoid missing critical emergencies and to better establish rapport.
• PES Initial Contact (Meet & Greet) for new Patient: ▪ Briefly (5 minutes) check in with patient within 30 minutes of arrival to PES ▪ Introduce yourself ▪ State the approximate wait time for full intake ▪ Ask about immediate SI/HI ▪ Assess for medical emergency (respiratory distress/severe withdrawal) ▪ Check in with attending/staff about patient status ▪ Enter standing orders for new patients (see PES Workflow )
2. The PES attending will delegate who is responsible for doing the patient drive-by (aka Provider
Initial Contact). If the attending asks you to do this, introduce yourself to the patient and quickly make sure he/she isn't planning or already doing something dangerous while in the PES. Also obtain contact numbers so that someone can start getting collateral info ASAP.
3. If, on your Meet & Greet, the patient is out of control, seems medically ill, or is threatening/attempting suicide and violence while in the PES, then tell the attending and staff. Tell the patient they will be seen for a more in-depth visit as soon as possible and try to give a ballpark time estimate (keeping in mind that things always run slower than expected, it could be many hours).
PES sign-out rounds: These occur at 7 a.m. every day of the week. These rounds are attended by the PES Attending for the day, the Social Workers ending and starting their shifts, and Nurses ending and starting their shifts. Unless you are called away for floor duties or emergent consults, if you have a patient left on the PES board, please present during morning rounds. General Approach to Starting a New PES Eval (after the meet and greet, see PES workflow above for logistics)
1. Review triage note and vitals 2. Review ED Note (if seen in ED, often not complete) & PES Nursing notes 3. Review IVT paperwork if present 4. Check CareEverywhere 5. Review labs if done already 6. Review medications 7. Review BAL, patients CANNOT be seen until their BAL is LESS THAN 100 (i.e. they are clinically
sober and therefore able to engage appropriately with interview and may have had symptom resolution); In general we estimate that BAL decreases by 50 per hour, however the DCRs and Crisis Clinic use the estimate of a decrease of 25 per hour (this is important if referring a patient to the DCR, attempting to get authorization for voluntary admission, etc.)
8. Check CLS
STAY COOL w/ agitated patients S–Stand at a safe distance, with your body at an angle to the patient T–Talk w/ even, concerned voice tone; consider timing of questions, directives A–Ask simple questions; avoid being provocative; agree to disagree; know where alarms are Y–Be a yellowbelly! Walk away if unsafe. C–Be concise and unambiguous . O–Observe surroundings and patient. Warning signs include being demanding, belligerent, not following directions, pacing, raised voice, motor agitation. O–Options . Give choices: food v no food; IM v PO meds; lights on v off. Having choices is empowering. L–Look(eye contact but no staring contest); -Listen (What does patient want?); Be neutral and remember that you control the situation –Lay down the law . Hillard/Zitek (2003) Emergency Psychiatry, p182
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9. Check records using “Chart Review” tab.. If prior PES notes and/or HMC inpatient psych DC summaries available, please review. Pay attention to DC summary recs regarding appropriateness for future hospitalizations (voluntary v. involuntary.)
10. Review notes in EPIC & CareEverywhere 11. See the patient 12. Get collateral as necessary (IT IS OK TO CALL FAMILY IN THE MIDDLE OF THE NIGHT
Crisis Solution Center
● The PES cannot refer patients to CDF if there is a wait list. ● CDF CAN manage active suicidal ideation IF the patient can verbally agree to remain safe. When
patients express concern for their own safety at CDF then it is likely not a good choice for them.
● CDF CANNOT manage active alcohol or opiate withdrawal. ● CDF will NOT accept patients with felony charges or who are sex offenders.
● Patient DO NOT need to be King Co. residents or have King Co. Medicaid to be accepted. ● Pt’s will need a three day supply of medications.
● Determine if patient has their own supply ● For psychiatric medications, a script can be sent
● For medicines for medical conditions, these need to be filled in the HMC pharmacy and the meds sent with the patient; print out the script and fax it to the Discharge Pharmacy. Be sure to write “Tube to 340” on the script and then stamp it as “Faxed.” Give the script to the patient’s nurse.
● See CRP v. CDF fact sheet in the PES for more information.
Crisis Respite Program (CRP):
● CRP CANNOT manage ACTIVE suicidal ideation, nor can they manage alcohol or opiate withdrawal.
● Is the patient barred from DESC? This will likely eliminate CRP as an option.
● To be eligible, the patient must be a King County resident with King Co. Medicaid. ● Patients will need an NDA either arranged with their current tiering agency or via the Crisis Line if
not currently tiered. ● Patients will need a month’s supply of medication.
● Determine whether the patient has their own supply
● If needs a supply, will need to print a script and send to HMC Discharge Pharmacy; write “Tube to #340” and stamp it as faxed, then give to patient’s nurse.
● See CRP v. CDF fact sheet in the PES for more information. ● PLEASE ALWAYS RECOMMEND AN ALTERNATE DISPO PLAN. Frequently patients are
declined to CRP for various reasons, even if CRP staff initially state there is a bed available. Community Call for a transfer or admit to HMC psychiatry If you receive a call about a person who may need psychiatric care but is not yet at a hospital, tell the caller to take the person to the CLOSEST ED, unless this is an DCR (See #2 below). It does not matter if the closest hospital has a psych unit or not: the person can always be safely transferred by ambulance if need be.
1. A sample response would be "I understand your desire to have them admitted to our facility, but please take them to the nearest ED, since we do not know what will happen to the patient between his current location and the hospital."
2. The exception to this is that an DCR can require us to take a patient at any time. If we don’t have a bed, the patient will be in the ED until a bed is available.
Medical ED to PES transfer 1. In order for the patient to be transferred from the ER to the PES be sure they have been
medically cleared:
2. Complete medical work up for altered mental status with labs (serum medication levels, BMP, CBC, etc), EKG, and possibly head CT if indicated
3. Medically cleared in the ED to us means: the ED attending would discharge the patient home if they had no psychiatric issues
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PES to Medical ED:
1. Contact the ED provider and explain why you think the patient needs to be on their side, reasons can be needs heart monitoring, is medically destabilizing, severe benzo/etoh withdrawal, is delirious etc.
2. Then provide suggestions for how they can treat their psychiatric problems 3. If your attending now approves the transfer and everyone else agrees with the transfer ask the
PES nurse to contact the medical ED nurse to facilitate the transfer
Steps for doing a Doc-to-Doc – PES Attending should do this but may allow resident to practice this skill.
1. A few general rules/guidelines: a. PATIENTS OVER 65 YEARS OLD REQUIRE MEDICAL CLEARANCE PRIOR TO PES
EVAL. b. Patients who present as a “Doe” should likely be medically cleared prior to PES
evaluation c. Medical clearance should be considered for all patients presenting due to concerns for
grave disability. d. Patients presenting with grossly abnormal vital signs (significant hypertension,
tachycardia) should be medically cleared. It can be helpful to have the triage nurse re-take vitals. Sometimes they normalize, sometimes they don’t.
e. Methamphetamine can cause presentations with tachycardia and hypertension. These
patients run the risk of significant dehydration, rhabdomyolysis, cardiac events, thus they should be medically cleared and may need to have a CK checked.
2. Find out who the patient is and open their chart. PES nurses can take a message allowing you to prepare for the doc-2-doc. Don’t feel need to immediately take the phone call.
3. Look at the triage sheet, vital signs, lab results, imaging results (if done), and medications given. It can be helpful to look for recent ED visits and/or inpatient admissions to a medical/surgical service as there may still be active issues from these prior visits that need to be addressed.
4. Determine the reason for the referral. Just because a patient asks to speak to psychiatry is NOT a reason for PES referral. (ED SW can provide non-acute patients with community resources, detox services, how to connect to mental health care, etc) Think of this as a consult. What question do they want answered? Typical reasons for PES referral:
a. Concern for SI, HI, and/or grave disability b. Most patients brought in on an IVT should
be PES cleared unless it is established that they have no psychiatric history and were intoxicated and their mental status has now cleared without ongoing safety concerns.
c. Medication refills can be provided by main ED without PES assessment if straightforward (e.g., refills of SRIs with clear plan for aftercare). In general, patients should see their outpatient providers and/or establish with a PCP to provide scripts until they can see an outpatient psychiatrist. We will assess and provide medications if the ED is uncomfortable doing so after discussing it with us. In general, the PES:
i. Does NOT provide scripts for stimulants, benzodiazepines or opiates. ii. Will NOT administer LAI. Refer back to outpatient providers.
Medical ED to PES transfer
- Confirm that pt is medically cleared
- Complete medical work up for altered mental status with labs (serum medication levels, BMP, CBC, etc), EKG, and possibly head CT if indicated
- Medically cleared in the ED = the ED attending would discharge the patient home if they had no psychiatric issues
PES to Medical ED transfer
- Contact ED provider and explain why they need to be transferred
- Provide recommendations for psych issues - If your attending approves this transfer, ask the PES
to facilitate the transfer
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iii. Will supply a minimum amount of meds, i.e., we rarely provide more than a month of medications and often will only give a few days worth. Keep in mind risk assessment, potential for diversion, reinforcing appropriate use of outpatient providers versus the ED
5. If labs were ordered, or further labs indicated, DO NOT ACCEPT A DOC-TO–DOC without the results being reviewed.
6. Review medical issues. All active medical issues should have been assessed and a plan should be outlined. Abnormal vital signs, labs, etc, should be explained and addressed (e.g., HTN medication, insulin, IV fluids, antibiotics, potassium administration, etc.) If further work-up is needed, follow-up labs, etc, tell the provider this is necessary before you can accept the final doc-to-doc.
a. If patient requires antibiotics, clarify meds, doses, course length. It is usually a good idea to request the provider send a script with the patient to the PES
b. If a patient has sutures, a cast/splint, burns, etc, what is the plan for follow-up? Are there wound care rec’s?
7. If you are concerned a patient may be medically ill and/or delirious go to the ED and eyeball the patient.
8. For patients who present with stimulant induced psychosis, it can be helpful to advise the ED provider to go ahead and medicate the patient with olanzapine, especially if there will be a long wait until the patient is seen. This can facilitate more metabolization and dispo in a more timely fashion.
9. FINALLY. Once the doc-2-doc is complete, add the patient to the “PES Emergency Services List” 10.77 Patients
A 10.77 refers to a patient who is brought from the jail for assessment and psychiatric placement on on Dismiss and Restore holds (somewhat similar to a 90 day MRO.) They have been deemed incompetent to stand trial by WSH evaluation (done at KCJ) and their charges have been dismissed in favor of psychiatric treatment/restoration.Cristina Maldonado, LICSW is the primary petitioner in these cases and the PES attending provides a second affidavit attesting to the patient’s psychiatric illness. This statement takes the form of an affidavit that you would write for any patient being referred to the DCR. The following steps occur with these patients.
1. The patient is medically cleared in the main ED 2. The patient is seen by an attending (often Dr. Romm, not a resident). The PES attending
reviews the legal paperwork, sees the patient in the ED, and writes an affidavit (but not an evaluation). The affidavit is then copied and pasted into the patients chart using a free text note labelled 10.77 Psychiatric evaluation. The affidavit is also printed out, signed, and given to SW.
3. Placement is found for the patient. This involves one of two scenarios: a) If this is at an outside hospital, the resident is not involved. b) If the patient is placed at HMC, the process is just the same as with a patient
detained in the field. The PES attending, ARNP, or resident will need to write a PES evaluation note, fill out standard admission paperwork and put in admit orders. The patient goes through the regular PES process and is not directly admitted to the floor (i.e. staff with PES attending as per usual)
B. 10.77 are not really complicated, but they do cause confusion. The issue is that they are sent to HMC to have Dr. Romm or someone else evaluate (not a resident though). Again, these patients require:
1. Medical clearance 2. Affidavit documenting need for involuntary treatment and 2) medical clearance.
Thus typically PES attendings can see them in the medical ED where they are medically cleared. Then, if there is a bed in the community the HMC PES SW will participate in placing them elsewhere. THUS - no admit or psych assessment is necessary!
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HOWEVER, it can be determined there are no beds or that the patient needs to stay at HMC. At this point they become an HMC patient like all others who are detained in the field and either the PES attending or resident will need to write an admit note. Dr. Romm (or the provider who wrote the affidavit and provided medical clearance) is NOT responsible for this and the assessment/plan will be identical in process to any patient detained in the field and sent to HMC for their ITA. Safety Safety features in the PES include:
● Four “panic buttons” are distributed around the PES: two in the east hallway of the PES, one under the Nurses’ station, and one under the Social Worker’s desk. Activate and stand clear of the doors—security doesn’t knock.
● A “panic telephone” is located under the video monitors at the Nurses’ station. Pick up the receiver and say, “Code Gray in the PES, Code Gray in the PES”
● The most important safety feature is the generous staffing allotment: if you are EVER concerned, ask another staff member or security to accompany you and standby while you interview the patient.
Violence and Assault Prevention:
1. Prior to any psychiatric interview, you should try to assess the potential dangerousness of the patient by checking in with other staff that is familiar with the patient.
2. You should also carefully review the patient’s medical record- THE BEST PREDICTOR OF
FUTURE BEHAVIOR IS PAST BEHAVIOR!
a. Some predictors of violence: High degree of intent to harm, frequent and open threats, concrete plan, history of loss of control, history of chronic anger, hostility, or resentment, history of childhood brutality or deprivation, history of fire-setting, cruelty to animals, history of prior violent acts and history of reckless driving
b. Some diagnoses and syndromes associated with violence: Antisocial and
borderline PD, mania, psychosis, intoxication, impulse control disorders, dementia
3. When interviewing a patient, position your chair so that you have unobstructed access to the door. You may wish to leave the door open for easier egress from the room. If you feel unsafe, trust your intuition! Get out of the room immediately, and call for help by yelling, “Staff!”, or pull one of the panic buttons.
4. There are three general ways to acutely manage aggression:
a. Verbal de-escalation b. Medications c. Seclusion and restraint
5. You should never perform any of these on your own. You may be asked by staff to order
medications, e.g., lorazepam, to reduce aggression and agitation. You should not be asked and will never need to participate in seclusion and restraint of patients because adequate staff is always immediately available.
6. Always debrief with staff and security after a code gray or after a patient was physically
touched involuntarily, i.e put into restraints
Dispo from the PES other than inpatient psychiatry Social work can help, if there is no social worker on duty or available, dispositions include:
● Next-Day Appointments (NDA’s) o If a patient doesn’t require hospitalization but needs immediate outpatient follow-up,
refer them to a Next-Day Appointment (actually within 72 hrs) at a Community Mental Health Center, which you can arrange through our pals at the Crisis Clinic. Be prepared with patient’s address, DOB, and a pithy HPI, and remember to fax your ER note to the treatment agency.
o As a last resort, we have some NDAs available through HMHS, but you should go through the Crisis Clinic first before you fill up our appointments.
● Private Pay Next-Day Appointments
o In the rare event that you get someone with gilt-edged insurance, call their agency and see if they will cover an acute evaluation. If you can get Blue Cross or Primera to say ‘yes,’ our Bellevue friends at Overlake offer a deluxe NDA Service. Before 5 pm call the Overlake Behavioral Switchboard at 425-688-5691, and be sure you have an insurance authorization in-hand.
o After working hours? Just call the 24 Hour Triage Nurse Pager at 206-645-6554. (They will also take cash, of course.) Naturally, most insurance agencies don’t work after-hours, so you may not be able to get their preauthorization, but please document that your tried to contact the insurance agency.
● PRCC (Harborview Psychiatry Resident Continuity Clinic) o This may be an option for very stable, low-risk patients needing psychotherapy
and/or medication management without social work/case management needs or treatment-interferring substance use that are able to wait up to several months for to their initial appointment. A link to the PRCC referral form is located at: http://psychres.washington.edu/
● Detox and Sobering Centers o Patients with a history of mild or moderate withdrawal and NO current suicidality may
be referred to one of the local detox facilities. To arrange, contact a detox facility and ask to speak to the intake supervisor. Typically, the detox facility will arrange for transportation from the PES, and most patients will be sent away with pre-packaged med.
▪ Complete discharge medication through first net, print on tamper-proof paper and then hand this to the nurse who will decide to either have it filled in house or give it directly to the patient. See PES Discharge meds
o Detox is NOT an appropriate disposition for patients with a history of severe withdrawal or seizures.
o The Sobering Center is a room with a rubber mat that takes in the chemically-
dependent without significant withdrawal history or suicidality. Case managers are available to assist with psychosocial issues, but medical support is not available.
● WASBIRT Program (Washington State Screening, Brief Intervention, Referral, and
o A Washington State pilot study whose initial success has resulted in ongoing funding. WASBIRT referrals are generally available first thing in the morning or as late as midnight if counselors are present. As the name suggests, a WABIRT counselor will do a screening and brief intervention with the patient in the PES. They may then qualify for outpatient follow-up of several motivational interviewing type sessions with possible referral to additional chemical dependency treatment as needed.
● Crisis Respite and Hospital Diversion Beds
o If a patient has a non-substance related Axis I disorder, requires more intensive monitoring than can be provided at a shelter, and needs temporary accommodation, they may be admitted to Crisis Respite at the Downtown Emergency Service Center (DESC).
● DESC Crisis Solutions Center
o DESC now has the Crisis Solutions Center (206-682-2371). They provide housing (for up to 17 days, 72 hours acutely with a second, 14 day stabilization stay) designed to help with acute psychiatric decompensation and referral to community mental health resources. Patients should not require detox, not be acutely dangerous to themselves or others (ie, requiring hospitalization), and not require special nursing needs. This level of care is meant to be similar to crisis respite.
● Homeless shelters o There are a number of homeless shelters in Seattle; phone numbers are listed in
PES. DESC is a shelter that also provides some case management and psychiatric services.
● Bus ticket
o Social Workers have a small fund for ‘therapeutic travel.’ If you have a patient who has been taking up a lot of services and says they would feel so much better if only they could get back home to Nashville where they just know there’s a cousin who will help them get a job at the salvage yard and be their AA sponsor, you can ask social work to buy them a bus ticket right out of town. The ticket is pre-paid and left at the Will-Call desk at the depot, so no cash changes hands. This happens about twice a year – quite rare.
Appendix
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If disaster strikes (emergency preparedness): If an event occurs that’s categorized as a “disaster” you will receive a page/text and/or hear an overhead announcement stating “internal disaster” or “external disaster.” If it is after-hours & you are the on-call resident you are therefore the “psych inpatient unit captain.” Immediately proceed to room 506 on the Maleng skybridge. Call your attending as soon as able to discuss the situation with them. Likely they will need to come into the hospital and will then take over as the “psych inpatient unit captain.”
If a patient dies on the psychiatry inpatient unit: Immediately call the attending on call. You will need to discuss with them if they need to come in to the hospital. They will walk you through the appropriate steps. Your responsibilities include:
● Making a plan about informing family with your attending, etc… The attending should be calling family.
● Completion of a Physician Death Note that essentially documents simple details surrounding death and the time of death. As the physician on call
● Coordination with
● Letting the chief know so we can help provide support and supervision
Phone Calls from Outside HMC
What should I do if an outpatient calls? 1. Ask for the patient’s full name, call back phone number, and where he or she is right now (get the
exact address). You never know what direction a phone call will take and you’ll need this information to call the patient back or help emergency services reach the patient.
2. If a patient won’t give you this information, be prepared to give them the hard sell, with “I need to have this information before I can talk with you. If you can’t give me this information, I’ll have to end this call. The crisis line number is (206) 461-3222.”
3. Once you have the patient’s phone number and address, identify the reason for the call. Most calls are:
● Medication request/re-fill request: NEVER prescribe any medication or re-fill a patient’s medications without first seeing the patient. Advise that you cannot prescribe medications over the phone. They should go to the nearest emergency room for care if they need medical attention immediately, including suicidal ideation. Otherwise, they should contact their primary provider on the next business day.
● Medication questions o Patients often call with questions about side effects they may be experiencing. If
the side-effects sound serious, document that you insisted that patient report to the nearest emergency room (assuming of course, that you DID insist). If the side-effects do not sound serious, say yes, that is a possible side-effect (no matter how unlikely or bizarre) and refer them to their provider.
o Do not change any doses to medications.
● Patient is trying to reach their primary provider: Assuming the provider is at HMC, inform the patient that this person is currently unavailable. We do not call individual providers or take messages after hours. The patient can call HMC during business hours at 206-744-3000 to be transferred to their PCP’s clinic.
● Patient is in crisis/request for hospitalization o Be sure you have the information discussed above (patient’s name, number, and
location). Many of these calls go to the ER social workers, but occasionally a call will get through to you. You’re too busy to provide telephone crisis support, so your primary goal should be determining if the patient needs to be seen emergently and what must be done to ensure patient safety.
o If the patient is suicidal, do a brief suicide evaluation (for plan, means, and intent). Determine if the patient is with someone who can support/supervise them.
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o If it sounds as though the patient may be in imminent danger, tell them you think they need to be seen right away and encourage them to call 911. Then hang-up and call 911 yourself, telling the dispatcher all the details, starting with who you are and ending with where the caller can be found.
o If not emergent, you can offer the patient the crisis line phone number (206) 461-3222) or presenting to the nearest ED for evaluation.
4. Have a low threshold for calling your attending. 5. Always write a brief note detailing the conversation with the patient:
a. In Epic, click Encounter at the very top. b. Enter patient’s name and DOB. c. Click magnifying glass in the Type text field. d. Select ‘Telephone.’ Click Accept to open. e. Write a note under the notes tab. f. Sign encounter. g. If asking for co-signer, enter on-call attending.
Legal Guardianship and Patient Admission Patients who have a legal guardian and need inpatient psychiatric hospitalization MUST be referred to the DCRs. This is specific to PSYCHIATRIC hospitalization. Patients who have a guardian have been deemed incompetent by the court, as a result they cannot make a decision to agree to psychiatric admission. In WA state legal guardians cannot determine placement and therefore cannot consent to psychiatric admission. This is an unusual case when it comes up and if the DCR you make the referral to does not understand the situation please involve your attending and the DCR’s supervisor if necessary.
How do I refer a patient for involuntary treatment? In WA, the laws surrounding civil commitment for involuntary psychiatry treatment are called the Involuntary Treatment Act (ITA). You may hear language at times, stating “the patient has been ITA’d.” In WA, third party evaluators called Designated Crisis Responders (DCRs*) that work for the county can perform initial detentions (120 hour ITAs). In WA, anyone (physician, family member, social worker, etc…) can request a DCR evaluation. Requesting DCR evaluation is called “referral to the DCR.” This section will walk you through how to refer patients to DCRs for consideration of involuntary psychiatric treatment or ITA. *Note: DCRs used to be referred to as “designated mental health professionals or D-MHPs” – if you hear the term D-MHP, that person means DCR. You can refer a patient to the DCR’s if:
(1) They have a “mental disorder” (organic, mental, or emotional impairment) that is directly related to their current high-risk status and has adverse effects on that individual’s cognitive/volitional functions, AND (2) One or more of the following is true:
(a) They pose a danger to themselves, with an imminent risk of suicide, as evidenced by statements made during the interview, recent behaviors, collateral information and/or past history, OR
(b) They are an imminent danger to others or others’ property, as evidenced by statements made during the interview, recent behaviors, collateral information and/or past history, OR
(c) they are gravely disabled and are at imminent risk of serious physical harm or even death resulting from a failure to provide for his or her essential human needs of health or safety as evidenced due to a mental illness by: a) repeated and escalating loss of cognitive or volitional control over his or her actions and b) not receiving care that is essential for his or her health or safety. Common examples: walking in traffic due to disorganized behavior or medical issues requiring on-going attention (e.g., infection requiring antibiotics, dehydration, electrolyte imbalance).
(d) they have a substance use disorder [Substance Use Disorder (SUD) ITA (a.k.a. “Ricky’s Law”). Officially took effect April 1, 2018 with full implementation by 2026 with goal of integrating the mental health and substance use ITA systems. Allows
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involuntary commitment for SUD treatment in a secure detox facility if a a person is at risk of harm directly due to a SUD. Washington will construct a total of 9 facilities for SUD but as of 2018, none built yet, so there is no way to use this law.
(3) AND, one of the following is true: (a) The patient is unwilling to be admitted voluntarily, OR (b) They are unable to consent to voluntary hospitalization, OR (c) You believe they are a “gravely disabled” (see separate section below.) *Based on discussion/agreement between HMC and DCR leadership, we no longer use
the term “poor faith voluntary” in our affidavit or other related documentation and instead simply make the case for detainment based on the above criteria, including evidence of difficulty adhering to treatment as a risk factor in favor or involuntary treatment.
If your patient meets these criteria, do NOT give any psychiatric meds (unless cleared by your attending in the case of intractable, emergent dangerous behavior) and:
● Ensure the patient does not have a significant medical issue that needs attention prior to psychiatric hospitalization – the DCRs often refer to this as “medical clearance.”
● Determine who will be the “affiant,” that is, who will write the affidavit. The affidavit is a legal document that affiant will write prior to the arrival of the DCR for evaluation of the patient that attests to why you believe the patient needs involuntary psychiatry care (ITA) and meets the above criteria. Affidavit template
● The affiant must have first-hand knowledge of the patient’s threats or behaviors; There can be multiple affiants.
● Residents almost always write an affidavit. If the patient has a case manager, the case manager will also write an affidavit (particularly if the patient is on a least restrictive order or “LRO”).
● Additionally, if a patient specifically said something threatening or regarding self-harm to a nurse, family member, etc, that person should also complete an affidavit. If you get collateral from a family member that is important in determining that someone is a threat to themselves, others or gravely disabled, ask that person to serve as an affiant and collect their name and telephone number.
● When you write your affidavit, include the following sentence. I spoke with XXX, phone number XXX, and they told me the patient said/did XXX. He/she would be willing to serve as an affiant.
Time Frames to be Aware of (if these time frames are violated, the patient’s civil commitment case may be dismissed).
If patient is detained by police and sent/brought in for evaluation, then patient must be seen by mental health professional (MHP) - not DCR within 3h and detained by DCR within 12h of official medical clearance to ED.
If patient is presents for observation and treatment (not detained by police) an MHP does NOT have to see the patient within 3h BUT once MHP has determined to refer patient to DCR for evaluation, then patient must be seen by DCR within 6 hours of the MHP notifying the DCRs of the need for evaluation. The clock starts once you have determined to refer the patient.
If patient is already admitted voluntary and requests to leave but you think they are a danger and want to refer them, then DCR must evaluate and detain the patient by the end of the next judicial day (5:00pm cut off) after the patient asked to leave the hospital.
If patient is a Juvenile, whether or not they have been detained by police, then once MHP has decided to refer patient, the DCR must detain within 12h.
Return to table of contents How to refer a patient to the DCR: If you decide you need to refer a patient to the DCR, first tell the patient and tell the primary team/ED provider (if applicable). The patient may already have a 1:1 sitter. Determine if the patient needs a sitter during the referral process to help keep them from leaving the hospital/self-harming/harming others. Unless they are immobilized and incapable of leaving or causing harm, they likely need a sitter.
1. If the patient has a case manager (i.e. “tiered”, meaning enrolled, with HMC, sound mental health, DESC etc): call the case-manager on call to request that they evaluate the patient. All tiered patients MUST be seen by a case manager prior to the referral. If you don’t know if the patient
has a case manager, the SW in the PES (24/7) or consults (8-5 weekdays) can help you find that information. You can also call the crisis clinic (number below) and ask if your patient has a case manager.
IF not tiered and/or case manager has completed their eval...go to step 2.
2. Complete your affidavit (Affadavit template), including direct quotes from the patient and your statement about your concern for serious harm to the patient (or someone else). For grave disability, include potential medical consequences. Include any information from affiants as well (see previous page regarding affiants). Please note: Medical students should NOT write affidavits. This is the resident or attending’s responsibility. See example affidavits below, in Appendix, or ask PES staff for examples.
3. Call the crisis clinic at 206-263-9202 and say that you would like to refer a patient to the DCR for consideration of detainment. They will likely need to take a message and call you back. Give your cell phone number if you are going to be moving around the hospital. The clock has now started (see the above “time frames.”)
4. The DCR will call you back and collect information from you about the patient, demographics (including DOB, address, SSN), diagnosis and current symptoms that are prompting the referral. Be prepared to verbally summarize the information you are putting into your affidavit and describe the medical consequences if the patient is gravely disabled (i.e. low sodium is risk for seizure and death, etc).
5. The DCR will ask for a callback number to notify you of the outcome. It is typically best to leave a callback number of the PES or the overnight pager in case you sign-out before the DCR visits the patient.
6. Complete your note, including identical quotes in your note and your affidavit. DO NOT copy/paste your entire affidavit in the note - this can lead to case dismissal by the court! However, the affidavit and your note should match up. Avoid abbreviations in your note and affidavit. Include the time that you completed the referral to the DCR in the plan of your note and in CORES.
7. Place the affidavit and a print-out of your note in the patient’s chart on the unit (staff will tell you where to put it in the PES) and let nursing staff know to be aware te DCR will be arriving. Sometimes (though rarely) the DCRs surprise us and arrive to evaluate the patient within 30 minutes of getting our call, so please be speedy in completing your documentation and placing it in the chart.
**If you complete your note and affidavit and it is the end of your shift, you can sign out calling the crisis clinic to the next resident. You CANNOT sign out writing the affidavit or note. ***If you have completed all of the steps above and are waiting on the outcome of the DCR evaluation, be sure to sign-out a “to-do” or action step to the next resident to follow up on the outcome. How do I write an affidavit? Affidavit template Note: you need to download the PRON onto your desktop often to get these links to work! It should pop open a separate Microsoft Word Document! Your affidavit should include the following:
● Identification: My name is Dr. Erasmus St. James, University of Washington psychiatry resident.
● The nature of your interaction with the “respondent” (a.k.a., the patient): I evaluated the respondent, Mr. Justin Case, in my capacity as on-call resident at Harborview Medical Center.
● Summary of the respondent’s presenting problem, psychiatric symptoms and relevant past history, using as many quotes as possible:
Mr. Case was brought to Harborview after waving a knife in front of the Seattle Police Department, and says “Suicide by cop, man, why didn’t those bastards just f-----g shoot me?” He has a mental disorder characterized by depressed mood, suicidal ideation, command auditory hallucinations . . . He has a history of six suicide attempts . . .
● Reason(s) why respondent should be detained involuntarily The respondent has a long history of serious suicide attempts, continues to endorse suicidal ideation with a plan and the intent to carry it out, is psychotic and impulsive, and is at very high risk of suicide given his recent behavior whereby he placed himself in significant danger of death with the intention of ending his life. *Note: also indicate why a less-restrictive option (such as outpatient care) isn’t going to cut it.
● Summary statement: In summary, I believe Mr. Case should be detained involuntarily as a danger to self. I would be willing to testify to the above in court.
● Signature, date, location (“Harborview Medical Center, Seattle.”)
Affidavit Tips ● The quotes and examples in the affidavit should be IDENTICAL to those in your clinical note.
However, you should NOT copy and paste your affidavit into your clinical note and your clinical note can contain information that your affidavit does not contain.
● Avoid jargon and avoid diagnostic acronyms like SIMD w/BPD and AVHs
● Write or type the affidavit on a special affidavit form ● Of you are not using the affidavit form, write “In lieu of affidavit” at the top of the page and list
the patient’s full name and DOB at the top: be sure and conclude with the “I would be willing to testify. . .” and write “Seattle, Washington” and the date under your signature.
● Do not stamp the form with the patient’s HMC identification card.
● Notes are written for treatment of patients, but the presentation of the information can be crucial to court proceedings. Affidavits are written for legal purposes and are not part of the HMC chart/business record
● When statements by the patient are made directly to you, please state that clearly. ● For example, instead of charting: The patient said he will jump off a bridge, chart: “The
patient told me he will “jump off a bridge." The use of quotation marks for patients' direct quotes is helpful, but the clarification that the statements are made to you is essential.
● Specific descriptions are most helpful for court as notes that just state conclusions or generalizations carry very little weight. ● For example, instead of charting: The patient has been threatening and RISing, chart: I
heard the patient yell, “I will punch my psychiatrist in the nose” and I saw him picking at objects in the air that I could not see”
● If you are victimized by a patient you might avoid being called as a witness if your chart notes are thorough and clear. Accordingly, if you are threatened or harmed by a patient, it is essential for you to chart how the patient made a threat (physically or verbally, with the actual threat stated), if you were afraid of harm, and if you were injured
Sample Affidavits for Involuntary Treatment The clinician who has requested that a patient be committed may need to write an affidavit, which documents the reasons why s/he believes the patient should be committed. Below are several examples of affidavits:
I, Anna Able, am a University of Washington psychiatry resident and have evaluated Mr. Joe Delta at Harborview Medical Center on January 2, 2000. Mr. Delta has a mental disorder meeting criteria for major depressive disorder, characterized by hopelessness, severe insomnia, poor appetite, psychomotor retardation and suicidal ideation. Mr. Delta overdosed on 10 tablets of alprazolam, a sedative medication, earlier today, and states that he plans on doing so again if he leaves the hospital. The respondent has a history of three suicide attempts prior to this one and has required involuntary treatment once before. He currently refuses voluntary psychiatric hospitalization. Because of his mental disorder and persistent suicidal ideation, Mr. Delta should be detained involuntarily as a danger to self. I would be willing to testify to the above in court.
Anna Able, M.D.
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Harborview Medical Center Seattle, Washington January 2, 2000
My name is Billy Bobb, a University of Washington psychiatry resident, and I have evaluated Mrs. Winona Willy in my capacity as on-call resident at Harborview Medical Center. Mrs. Winona was referred to Harborview by her nursing home due to her refusal to eat and her 20-pound weight loss over the last 2 weeks. Due to her poor intake of fluids, her blood pressure is abnormally low and the patient is at risk for stroke, heart attack, kidney failure and death. Mrs. Winona has also refused to take Coumadin, a blood-thinner required to prevent a clot from forming in her heart; this may result in stroke and death. The respondent has a mental disorder characterized by severe memory loss, inability to recognize relatives, inability to care for herself and paranoid delusions regarding her food. She likely meets criteria for Alzheimer’s disease with psychotic features. I believe that, due to her mental disorder, Mrs. Winona is unable to adequately care for herself, is at risk for serious medical consequences, and should be detained involuntarily as gravely disabled. I would be willing to testify to the above in court.
Billy Bobb, M.D. Etc.
I, Carol Channing, in my capacity as on-call psychiatry resident at Harborview Medical Center, have evaluated Mr. Lou Prole on October 10, 2000. Mr. Prole was brought to Harborview by the Seattle Police Department today because of threats he made to kill his girlfriend. Mr. Prole has a mental disorder characterized by extreme paranoia, command auditory hallucinations telling him to kill his girlfriend and homicidal ideation with the intent to kill her should he leave the hospital. He has a long history of schizophrenia requiring four hospitalizations, but also has three Against-Medical Advice discharges and a history of assaultive behavior towards hospital staff. Mr. Prole is willing to be admitted to the hospital but must be considered a poor-faith voluntary due to his history and his current refusal to contract for safety. I believe that due to his mental illness, Mr. Prole presents a danger to others and should be detained involuntarily. I would be willing to testify to the above in court. Carol Channing, M.D., etc.
Please note that you should avoid abbreviations and technical terminology. Discuss medical issues in lay-terms (e.g. low potassium rather than hypokalemia).
What does “poor faith voluntary” mean? This language (poor faith voluntary) should NOT be used in notes or affidavits. However, you may hear it used by RNs, SW, PES attending. This phrase indicates a patient who cannot fully consent to voluntary hospitalization (i.e. lacks capacity to make this decision) or who will not participate in the requirements of voluntary hospitalization, including taking medications, attending groups, and participating in treatment team interviews. If the patient requires inpatient treatment, refer them to the DCRs and explain in your affidavit why the patient cannot consent to voluntary hospitalization or are unwilling to participate in voluntary hospitalization. Possible reasons to refer a patient who states they will go to a psychiatry hospital: Non-adherence to recommended psychiatric treatment
● History of AMA discharge from hospital, especially within the last year ● Protracted failure to follow through with outpatient treatment
● Refusal of psychotropic medication treatment Inability to give informed consent
● A patient who is unable to understand or unwilling to sign a voluntary treatment agreement cannot be admitted voluntarily. As with any informed consent procedure, a potential voluntary patient must be able to appreciate the procedures, risks, and benefits involved in hospitalization. Consider lack of capacity with patients who have dementia, catatonia, severe mania or psychosis, intellectual disability, or a patient who already has a guardian.
Ambivalence about entering the hospital
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• A patient who repeatedly changes their mind about being admitted or taking clinically indicated medication.
Assaultive behavior
● Recent violent behavior ● History of assault in treatment settings
● Inability of patient to agree to not harm others. Inability to stay safe on the unit
● Self-harm behavior in the PES or on Med/Surg (i.e. banging head on wall, attempted cutting, foreign body ingestion)
● History of self-harm behavior during admissions
● Inability to follow staff re-direction What if the DCR does not detain my patient? If you strongly believe the patient would be unsafe if unreleased, call the crisis referral line again and request to speak to a DCR supervisor. State “I would like to speak to a DCR supervisor about a patient who was not detained.” You may need to write another affidavit and addend your note and re-refer the patient to the DCR for evaluation. Call your attending for help.
Subpoena and Court
• Every time a patient you referred gets detained, you will receive a court subpoena that lists the court date (if you go off shift before the decision to detain, please have the next on-call resident check whether the patient was detained in the paper chart and write down the court date aand phone number and email this information to you). You should call the ITA Superior Court at 206-744-7774 between 10am and 3pm the day before the court date to check if you need to testify. Often, you will receive notifications of needing to testify from the DCR and/or PES. Most of the time, particularly with strong documentation/affidavits, you do not end up needed to testify.
• Pointers for testifying o Prior to court, please your declaration for the case and/or the pertinent chart notes o Court procedure:
▪ Call prosecutor paralegal according to instructions on subpoena (206-744-7774)
▪ Appear in court ▪ Participate in interview by lawyers
▪ Possibly meet with respondent ▪ Enter the courtroom, raise your right hand, and be sworn in by the Judge
▪ Answer questions of prosecutor:
• Keep your voice loud and clear. Patients often try to talk over witnesses during our hearings and the record needs your voice to be louder than the patient’s voice
• Provide your qualifications including your education and experience
• Explain your role in the medical field regarding your interaction with this particular patient
• Answer the question being asked, but don't be afraid to provide detail
• If a question does not make sense to you, please state that you need the question clarified or rephrased. Don't try to guess what the point of a question is
• If an objection is made, stop talking. The Judge will make his/her ruling and the prosecutor will let you know if you should finish your answer or will ask you another question
• You are an expert in the case. Speak with confidence. Try to refrain from couching your opinion with phrases such as "I think..." or "It appears to me..."
• If lab values are relevant, be prepared to testify to what the normal range for the lab value is and why the deviation from that range is dangerous. State with authority what harm can come to the patient if the patient does not receive care for that condition, or refuses care for that condition
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▪ You are also a fact witness in our case. Therefore, you will testify regarding the details of your interaction with the patient (i.e. the patient's physical presentation/demeanor, statements and actions made by the patient, etc.)
▪ Answer questions of defense counsel during cross examination:
• Try to refrain from being argumentative with defense counsel
• Once again, if the question doesn't make sense, speak up and get clarification
▪ Answer any additional questions of the prosecutor or the Judge
▪ Be "excused" from the courtroom. This means you are free to leave! ● Video use in ITA Court: Statutory Change June 2018 allows the petitioner, respondent,
witnesses, and Judge to be present and participate in ITA hearings in person or via video. o The Judge appears via video from chamber o The prosecutor and witnesses present in court appear via video from ITA courtrooms o Witnesses may appear via video with the installation of the Cisco Webex Teams App to
cell phone, tablet, or computer
ITA proxy information during Night Float ● Proxy is a request for another person to testify on your behalf. ● Proxy can only be requested if you will be working at night or on vacation on the day of
court. o If you are on weekend call and not on nightfloat or vacation the next week, you cannot
request proxy. You will always be excused from clinical duties if you have to testify. You may need to cancel patient appointments.
o ITA holds are now 120 hours (rather than 72 hours). ● Procedure for PES
o Give a copy of your signed affidavit (print 2 and sign both) with your email address to the PES social worker. SW will complete the process.
o If no PES SW:
▪ Fax the affidavit, PES note (or consult note or other documentation you wrote after evaluating the patient), and any relevant supporting clinical evidence to 206-205-8170. Include your contact information so they can get a hold of you, either via your pager, cell phone, or email.
▪ Email the prosecutor's office ([email protected]) to REQUEST proxy. ● Procedure for CL/IP:
o Do not request proxy. You will be excused from clinical duties to testify. If you are not available on the court date, discuss with your clinical team and another team member (e.g., your attending, social work) will testify in your place.
● Proxy must be approved by the prosecutors. Due to the high volume of requests, they no longer confirm proxy requests. Unless they tell you otherwise, you may assume your request was granted. To double check, you can call them at 296-8936.
● Proxy can only be used if the clinical note has appropriate documentation. This includes: o Opening statement such as “All statements in the following evaluation were made directly
to me by the patient unless otherwise noted and I observed the following:” o Quoted patient words o “I” statements (“I heard the patient say”, “I saw the patient do…”) and a clear description
of the patient’s actionable behaviors. Quoted statements in your affidavit should be IDENTICAL to those in your clinical note.
• You CANNOT request proxy if the patient made a personal threat against you and that is the grounds for detention. In that case, you are required to appear in court. If that will interfere with your duty hours (i.e. you are on night float), please contact the HMC chief residents to help come up with a solution.
Hospital Pre-Authorization Be sure to document the result of your attempt to obtain authorization in the chart! If no weekend psychiatry social worker available, please check with PES social worker. If no PES social worker, below
are steps you can take. Note that we do not require residents to do social work and your clinical responsibilities supersede getting hospital pre-authorization for a transfer. Involuntary Admissions: Unfunded or Medicaid patients do not need pre-authorization for involuntary admissions Voluntary Admissions:
● Unfunded Patients: ● King County residents: call Crisis Connections 24/7, 206-461-4858, for hospital authorization
● Other Washington state counties: pre-authorization is needed from county of residence ● Out of state: pre-authorization through King County-call UBH 206-461-4858
● Residency status is not clear: pre-authorize through King County call UBH 206-461-4858
● Medicare: If a patient has Medicare, he or she can be admitted without pre-authorization ● Managed Medicare: If a patient has Managed Medicare, you will need to contact the
management company to determine if HMC is a preferred provider. If this is the case, the patient will need to get pre-authorized through the management company. If not, then the patient will need to be admitted to another hospital that is preferred.
● Private/commercial insurance: Determine if HMC is a preferred provider. If this is the case, obtain authorization for admission. If not, then the patient will need to be admitted to another hospital that is preferred.
● Private/commercial insurance with exhausted benefits (i.e. several hospitalizations in one year) or limited/no mental health coverage: These patients need to be authorized through King County, or the patient’s county of residence.
Algorithm for patients who demands to leave AMA on med/surg:
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Sign out on CORES Guidelines: See below for screen-shot that shows you what CORES looks like and the specific boxes! INPATIENT 1. ILLNESS SEVERITY: select from one of the below options
● ‘Watcher’: a sick patient and/or a patient that nursing will likely page about – all watchers must be signed out verbally
o medically active o psychiatrically active
● ‘Stable’: no major interventions anticipated over the cross-cover shift
● ’Discharge’: use this label if discharge is occurring during the cross-covering resident’s shift.
Remember, it is primary team’s responsibility to do all discharge planning, orders, and
medications.
Note: in psychiatry we do not use the ‘Unstable’ label as this refers to hemodynamically unstable patients who require ICU level of care.
2. PATIENT SUMMARY: type in the below:
● COVID-19 Status ● Legal Status: Involuntary or Voluntary
● Brief summary (should not be copy and pasted assessment) of the patient. This should be updated daily and reflect:
o Age and gender
o Primary diagnosis and major co-morbidities
o Reason for admission
o Key 24 hour events with big picture plan (do not need minor daily med changes, only
what is relevant to cross-cover resident)
● History of violence? Yes or No
● Past medical history: List patient’s medical problems here. If unable to obtain or pt is a poor
historian, please indicate that. Indicate if any particular condition is poorly controlled that could be
be an issue over cross-cover shift (i.e, HTN and DM)
Include if relevant to your patient: ● DNR/DNI: this is unusual on psych inpatient, so please let cross-cover resident know if this is
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applicable to your patient.
● Consults: List services who are helping manage the patient that cross-cover resident can call for
help
● Important Contacts? i.e. legal guardian; family member who could help if AMA?
3. ACTION LIST: Click the “blue plus sign” to add a “to-do” and select a due date. ● Here is where the “to-do” list for the cross-cover resident goes. Due dates are especially helpful
for over the weekend. Remember to include instructions for the resident on what to do with any
results that they are following up on in “Situational Awareness.”
● If there are no action items for your patient, then leave this section blank.
4. SITUATIONAL AWARENESS: Here type out the anticipated problems and the “if/thens” that could occur over the cross-cover shift.
● Every patient requires “if/thens” for:
o Anxiety/Agitation
o Insomnia
o Pain
o AMA discharge (if voluntary)
● Each PRN should have a unique indication. For example, you should not have both ibuprofen and
acetaminophen ordered for ‘pain.’
● Include all other if/thens here, for example:
o instructions on what to do with action list items
o atypical VS parameters and plan for management
o insulin (i.e. hold parameters)
o complex situations where compelled meds are being given (or not given)
● This is where cross-cover residents can type notes or updates to the primary team
5. NOTES (Other): Here is where you can type in notes that are pertinent to the primary team only. CONSULTS 1. ILLNESS SEVERITY: select from one of the below options
● ‘Watcher’: a sick patient and/or a patient that nursing will likely page about – all watchers must be signed out verbally
● ‘Stable’: no major interventions anticipated over the cross-cover shift
2. PATIENT SUMMARY: type in the below:
● COVID-19 status ● Legal Status: Involuntary or Voluntary
● Brief summary (should not be copy and pasted assessment) of the patient. This should be updated daily and reflect:
o Age and gender o Primary diagnosis and major co-morbidities o Reason for consult o Key 24 hour events with big picture plan (do not need minor daily med changes, only
what is relevant to cross-cover resident) ● History of violence? Yes or No
3. ACTION LIST: Click the “blue plus sign” to add a “to-do” and select a due date. ● Here is where the “to-do” list for the cross-cover resident goes. Due dates are especially helpful
for over the weekend. Remember to include instructions for the resident on what to do with any
results that they are following up on in “Situational Awareness.”
● If there are no action items for your patient, then leave this section blank.
4. SITUATIONAL AWARENESS: Here type out the recommendations and any specific if/thens for the team.
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IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON FOR KING COUNTY
IN RE THE DETENTION OF ) NO. SEA ) ) DECLARATION
[Subject] Respondent )
PAGE 1 of 55 I declare the following:
I, ________, am a University of Washington Psychiatry Resident and evaluated [Subject] at [Company Address] on [Publish Date]
[Subject] has a mental disorder meeting criteria for Bipolar Disorder characterized by labile mood and impulsivity leading to dangerous behaviors, including discontinuation of his HIV treatment, extensive methamphetamine use, and unprotected sex with multiple partners (he reports more than 50 in the past two weeks) despite his known HIV diagnosis. He also has a history of Methamphetamine Use Disorder, Depression, and Post-Traumatic Stress Disorder. [Subject] was admitted after threatening to commit suicide by jumping off of a bridge following several weeks of methamphetamine use. Without additional treatment, he is currently at high risk of suicide given his recent attempt and diagnoses. Additionally, his untreated behavior and untreated HIV constitute a significant public health concern. [Subject] currently refuses voluntary psychiatric hospitalization. Because of his mental disorder and risk of suicide as documented above, [Subject] should be detained involuntarily as a danger to himself. I am willing to testify to the above facts in any subsequent judicial proceedings. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
________ Printed Name Signature
[Publish Date] [Company Address], Seattle, WA
Date Place External link to affidavit [here]. For proper formatting, don’t edit in browser. EKG Policy
● All EKGs should be ordered as early in the morning as possible to help nursing facilitate early collection.
● All EKGs should be read by the primary team during typical work hours to help reduce cross-covering resident workload.
● All EKGs, regardless of their clinical indication, must be read by a physician as soon as the EKG results are ready. This includes EKGs that are ordered for QTc monitoring. Reading an EKG must include initialing the paper EKG so that it may be filed in the patient's paper chart. It is the primary team's responsibility to track their patients' EKG orders, particularly which patients have EKGs pending collection.
● If a team is signing out for the day and there is a pending EKG that was unable to be completed during the day, the primary team must sign out the pending EKG as an "action item" for the cross-covering resident to complete.
● Cross-covering residents may be asked by nursing to read completed EKGs. Cross-covering residents should read these EKGs as soon as they are able, being sure to initial the EKG and then hand-off to the results of the EKG to the primary team.
Medical Students on the HMC Inpatient Psychiatry Rotation: of note, sometimes residents or away students are on call or rotate on other services. Any med student on call during a WEEKDAY should be in the PES (though the short-call resident can grab them from the PES for an interesting consult). Any med student on all during a WEEKEND should be with the resident for the entirety of the day.
1. Grading a. 60% clinical
i. CEX (clinical skills exam) - evaluates student’s ability to connect and interact with patients
ii. OCPs (oral case presentation) - evaluates student’s ability to summarize and organize information
iii. Topic presentation - can be on anything! b. 40% exam
2. Call Responsibilities a. Weeknights: students are assigned to the PES b. Weekends: students are to told to stick with the resident on call
3. EMR and notes: students should be adding to the chart 3x/week a. Progress Notes - medical students can write notes (including progress) as long as
they are reviewed and contain all the below elements AND the attending is present for all parts of the interview/exam. NO NOTES ON CALL!
i. Requirements 1. ID (patient identifying statement/one-line) and CC (“chief complaint”) 2. HPI that includes information on how patient is tolerating their current
medications – document if interpreter is used 3. ROS (need at least two from two separate systems) 4. MSE – use the template in the power-note as a model – must have all of
these elements!! a. - Appearance b. - Behavior/Activity c. - Speech d. - Affect e. - Mood f. - Thought process g. - Thought content h. - Suicidality i. - Orientation j. - Attention/ Concentration k. - Memory l. - Insight m. - Judgement n. - Other
5. Other objective findings: vitals and labs or other exam findings if relevant 6. Assessment with suicide risk assessment 7. Diagnoses – update these using the ORCA “Add Diagnosis” feature so
they autopopulate ii. Statement at the end of note: “I was present with medical student for the
service. I personally verified the history of present illness and performed the physical examination and medical decision making. I have verified all of the medical student’s documentation for this encounter.”
b. Interim and discharge summaries
Residents Role in Medical Student Education 1. Residents should view themselves as the students’ primary contact 2. Residents should review safety tips and procedures for medical students as part of their first day.
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3. Feedback: frequent and private - make sure your attending is aware of your feedback 4. Review notes thoroughly and give feedback.
Anesthesia-Assisted MRI: Below is the procedure for ordering and arranging a MRI for patient who requires sedation (and helps you determine IF a patient needs sedation for a MRI).
1. Place order for MRI in ORCA like you typically would (this triggers the Radiology Scheduler to process the order and call the unit/nurse to have an MRI Screening Form completed.) (See below for copy of this screening form). Be sure to tell the patient’s nurse you want the patient to have sedation so that they indicate this on the screening form. Closing the communication loop on this is important.
2. You will next need to complete the Screening Tool for Moderate Sedation Anesthesia Consults Form (see below) to help determine if anesthesia consult is necessary. If the patient has an absolute contraindication and MRI is necessary, consult Anesthesia. If the patient meets criteria for any of the “Mandatory Consult” boxes, consult anesthesia. If the patient has 2 or more risk factors for moderate sedation, consult anesthesia. Let them know the urgency of the situation.
3. Fax the Screening Tool for Moderate Sedation Anesthesia Consults Form to the Radiology Scheduler (the unit clerk should be able to help with this – 206-744-2295). (If this is a STAT MRI, after discussion with anesthesia, call the OR Front Desk at 4-8800 to talk with the Anesthesia-in-Charge (AIC) to inform them. They will then coordinate with anesthesia.)
4. Once the Radiology Scheduler has received the 2 above forms, they will schedule, matching the appropriate anesthesia and radiology resources. They will then alert the unit nurse of the scheduled MRI appointment time.
5. Go here to look at a flow-chart that documents the above.
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NURSING FILLS THIS FORM OUT
This section nursing fills out too, but you will need to
coordinate with them. If yes to any questions in part C,
YOU need to fill out the below Screening Tool Form.
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THE RESIDENT needs to fill out the below form if the answer “yes” is true for any question under section C in the above form – it will help you determine if an anesthesia consult is necessary (you will need to share it with anesthesia). All forms, regardless if anesthesia is involved or not, need to be faxed to the Radiology Scheduler (206-744-2295)
FLOW CHART for how to access Sedation for MRI
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EPIC RESOURCES SMARTPHRASES SmartPhrases are templates or short phrases created by an Epic user. They can be shared among users. Some have been shared to you already and some are Facility SmartPhrases all users can acces. Once you have a SmartPhrase created, you import into a note by putting a period/dot “.” before the title of the SmartPhrase. List of SmartPhrases shared to residents during AY20-21.
• HMCPSYCHDISCHARGESUMMARY
• HMCPSYCHCROSSCOVER
• HMCPSYCHCONSULTPROGRESS
• HMCPSYCHFALL
• HMCPSYCHMSE You can create a SmartPhrase. Go to Personalize (at the very top) -> My SmartPhrases. ALL VIDEOS Transfers CL to Psych: https://youtu.be/uEM0prOp3Kg Epic Tabs: https://youtu.be/68s1lt3IUNo Flowsheets: https://youtu.be/8pC9OrxwTSM Patient Lists: https://youtu.be/CzBCtRefUr0 CL Initial Note: https://youtu.be/VgYYYrT6Qvs CL Progress Note: https://youtu.be/EzScpM-MJgg Epic 101 Inpatient Psychiatry: https://youtu.be/5t2i09HGnTQ Page Break OTHER RESOURCES
• To get remote support with Epic during call or on rotation, call the UW Medicine Epic Hotline at 206.520.2255
• Dr. Green’s Epic Tips – super helpful and has PES link! drgreentips.com/epic
• Short videos that have been made for providers in all specialties: https://one.uwmedicine.org/d1/Pages/20210114_D1%20Epic%20Practitioner%20Videos.aspx.
• CORES Do’s and Don’ts: CORES Do's and Don'ts
• Add your pager to CORES: How to add pager to CORES
ITA proxy information during Night Float ● Proxy is a request for another person to testify on your behalf. ● Proxy can only be requested if you will be working at night or on vacation on the day of
court. o If you are on weekend call and not on nightfloat or vacation the next week, you cannot
request proxy. You will always be excused from clinical duties if you must testify. You may need to cancel patient appointments.
o ITA holds are now 120 hours (rather than 72 hours). ● Procedure for PES
o Give a copy of your signed affidavit (print 2 and sign both) with your email address to the PES social worker. SW will complete the process.
o If no PES SW:
▪ Fax the affidavit, PES note, and any relevant supporting clinical evidence (ED note, nursing notes, case manager affidavit) to the prosecutor (fax: 206-296-8720). Include your contact information so they can get a hold of you, either via your pager, cell phone, or email.
▪ Email the prosecutor's office ([email protected]) to REQUEST proxy. Copy PES director Paul Borghesani ([email protected]). See sample email at end of proxy section.
● Procedure for CL patients or inpatients o Fax the affidavit, PES note, and any relevant supporting clinical evidence (ED note,
nursing notes, case manager affidavit) to the prosecutor (fax: 206-296-8720). Include your contact information so they can get a hold of you, either via your pager, cell phone, or email.
o Email the prosecutor's office ([email protected]) to REQUEST proxy. See sample email at end of proxy section.
▪ For psychiatric inpatients: Copy the patient’s attending and J Veitengruber ([email protected]) as well as SW supervisor Nicole Zacher ([email protected]).
● Proxy must be approved by the prosecutors. Due to the high volume of requests, they no longer confirm proxy requests. Unless they tell you otherwise, you may assume your request was granted. To double check, you can call them at 296-8936.
● Proxy can only be used if the clinical note has appropriate documentation. This includes: o Opening statement such as “All statements in the following evaluation were made directly
to me by the patient unless otherwise noted and I observed the following:” o Quoted patient words o “I” statements (“I heard the patient say”, “I saw the patient do…”) and a clear description
of the patient’s actionable behaviors. Quoted statements in your affidavit should be IDENTICAL to those in your clinical note.
• You CANNOT request proxy if the patient made a personal threat against you and that is the grounds for detention. In that case, you are required to appear in court. If that will interfere with your duty hours (i.e. you are on night float), please contact the HMC chief residents to help come up with a solution.
Sample email to [email protected]: Dear Prosecutors The following patient was detained in the PES/medical unit/inpatient unit. Name: Record Number: U# Age: Date of Hearing: ***find on your subpoena*** As Dr. XXX works nights/will be on vacation, she/he/they would appreciate it if you would grant the privilege of testimony by proxy. Thank you.
DCR Referrals during HMC Call DCR numbers: 206-263-9202 or 206-461-3210 (after hours) Court number: 206-744-7774 Active DCR Referrals
1. All ongoing (result unknown) DCR referrals must be signed out. Include the following: a. Normal I-PASS sign-out b. Time-frame of the referral – when was referral placed c. Who made the referral d. If/then for result of referral
i. If detained, then… (e.g. prescribe a specific medication, compel medication, etc.) ii. If not detained, then… (e.g. safety plan with patient, okay to discharge, escalate
to supervisor) 2. The resident receiving the sign-out must:
i. Ideally, DCR will call you (on-call pager number now on affidavit template). Other ways to find out:
1. Visit patient’s paper chart (most reliable way). Regardless of outcome, DCR will leave paperwork. If detained, find the subpoena – contains resident’s name who referred patient, court date, number to call for follow-up.
2. Call floor and ask RN to check chart. Ask RN to give you the court date and number – especially helpful if you are at home and the only reason to come in is to check. **Sometimes RN calls you with result of referral after DCR leaves
ii. Call Crisis clinic (206-461-3210) and ask to follow-up on referral. b. Sign out the active referral if the DCR does not arrive during the shift.
i. For CL, DCR has 6 hours in which to see the patient ii. For inpatient, DCR has 1 business day – this means that if a referral is placed on
Friday night, DCR has until Monday night! c. Follow ‘if/thens’ provided. If no ‘if/thens’ provided, ASK for them during verbal sign-
out. d. Alert the resident who made the referral about the outcome via UW email. Include
court date in email (on subpoena). This step is necessary as your colleague needs to know if they must go to court.
e. Escalating to a supervisor i. If we do not agree with the outcome of a DCR referral, we may call the DCRs to
escalate to a supervising DCR. ii. State “I would like to escalate this case to a supervisor.” iii. If you were not signed out what to do and have concerns about a patient, always
discuss with your attending prior to escalating. What to do if you referred a patient?
1. Find out the result of the referral. a. Ideally, a co-resident will email you the result (if over the weekend). The court date
should be included. b. If this is your inpatient or CL patient, go to their hard chart and look for the DCR
paperwork. Your subpoena will be with the paperwork. Subpoena contains the court date. c. You can call the crisis clinic and ask for the result. (206-461-3210)
2. If detained, you must legally call the court the day before the court date between 1000-1500. a. Court #: 206-744-7774 b. If no one answers, leave a message with your cell #
3. If on nightfloat or vacation on the day of court, you may request proxy (see above section).
