LSU-HSC Department of Psychiatry Buddy Call Checklist · LSU-HSC Department of Psychiatry . Buddy...

LSU-HSC Department of Psychiatry Buddy Call Checklist Over the course of the buddy call shifts, interns are expected to be trained and oriented in the following areas. Please have the resident on call with you sign at the bottom and initial when a task is completed. ____ Know & perform all the components of obtaining sign out (see on call guide sheet) ____ Know where PEC forms are and how to fill them out correctly ____ Know the difference between PEC, CEC, RPC, OPC, and JC ____ Know how to fill a Formal voluntary form and discharge form ____ Know how to consult another service including the form and verbal contact. ____ Know how to initiate and manage physical restraint/seclusion orders. ____ Know how to document an H & P on Doctors Choice software in the PCU ____ Know how to place admit orders on patients in the PCU through Netaccess/POE software ____ Know and perform the steps needed to discharge a patient from the PCU (see guide) ____ Know and perform the steps needed to admit a patient from the PCU to 10 psych ____ Know the steps needed to admit a patient from the medical floors (psych consult service) to 10 psych. ____ Know the protocol/paperwork involved in discharging a patient back to jail or correctional facility ____ Know how to check if a patient has benefits and can be transferred ____ Know how to fill transfer paperwork and initiate a transfer request through house supervisor. ____ Know all the steps needed to evaluate and transfer a child/adolescent to Brentwood Hospital if indicated ____ Know how to check if a patient has VA benefits by calling their AOD ____ Hold the psych pager for an entire buddy shift acting as primary on call

____ Coordinate and oversee that all the daily notes are completed on the 10th floor between the moonlighters, students, and you (see moonlighting guidelines) ____ Know how to prepare billing sheets for the covering attending to complete ____ Know what situations require you to see a patient on the 10th floor and write an on- call note rather than handling over the phone Have the on call Buddy residents that you trained with fill out the portion below: Signature Date Initial ____________________________________ _______________ ___________ ____________________________________ _______________ ___________ ____________________________________ _______________ ___________ ____________________________________ _______________ ___________

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LSU Health Sciences Center Department of Psychiatry

ORIENTATION TO CONSULTATION-LIAISON SERVICE

Welcome to the Consultation & Liaison service for the Department of Psychiatry. We will be working with all departments in the hospital that care for patients. Our focus will be on the entire patient, not just their medical and/or psychiatric problems.

Requirements

1. Resident should contact or speak with consulting team regarding specifics of request and issues involved with the case. Timely written initial evaluations of patients with history and mental status, diagnoses and treatment recommendations. Evaluation and follow-up requires review of the chart, old chart if available, consultation with nursing staff, review of all medications and lab, review of vital signs and nursing/case management notes, and obtain collateral from ancillary sources if appropriate. Verbally inform consulting team of recommendations after the patient is seen with the attending.

2. Complete billing forms on new patients.

3. Please do initial evaluation and follow-up on progress notes. I will complete the consult form and keep the bottom 2 pages of the consult for my records.

4. Delirium is considered a psychiatric emergency. Delirious patients should be seen on the day of the initial consult as soon as possible.

5. Follow-up of initial consults as appropriate.

6. Begin to arrange for discharge from a psychiatric standpoint after the first encounter. This means arranging for a safe place to stay on discharge and psychiatric follow-up. The substance abuse case manager should be notified as soon as possible.

7. The resident attends morning report to discover any new consults overnight or after weekends and holidays.

8. The resident must see all patients on a PEC daily. These patients are not allowed to smoke.

9. The resident arranges for the call residents and faculty to follow the consult patients on a PEC over weekends/holidays and any unstable delirious patients.

10. The resident should see all Medicare patients before the attending.

11. If medical students are available, the primary duty of the resident is to evaluate the student's write-up of the patient, ensure the accuracy of the report, guide the student toward correcting deficiencies in history or mental status examination, and assist the student in completing a differential diagnosis and the five axis evaluations.

12. When the student completes the descriptive diagnosis, it is the resident's responsibility to complete a case formulation. To complete the formulation, the resident should be able to address these five questions about the patient:

1. What ego defenses was the patient using at the time of the exam?

2. What is the personality or character diagnosis of the patient at the time of the exam?

3. What current stressors interacted with which biological and psychological vulnerabilities to create the symptoms that cause the hospitalization?

4. What problems must be addressed to restore safety to continue care at less restrictive levels of care?

5. What inpatient or outpatient psychiatric management would benefit this patient?

13. Reading the assigned chapters in Kaplan and Saddock "Synopsis of Psychiatry"

for the medical students and leading discussions of this basic material with the

medical students.

14. Focused reading on C/L Psychiatry as developed by the faculty.

15. Literature searches regarding patients with complicated cases

16. The resident will also follow patients seen in outpatient clinic after discharge from hospital while on the service.

17. Perform brief psychotherapy with at least two patients per month while the patient is hospitalized.

18. Oversee and educate the medical students on C/L Psychiatry Rotation.

19. When a patient is transferred to 10 psych from the consult service, the resident is responsible for completing a full admit note including a physical exam. A carbon copy of the consult is not sufficient. The resident is responsible for the admit orders and admission approval form. The resident also copies the PEC and CEC, consults, and progress notes. The original PEC and CEC along with copies of the psych consult and progress notes is left with the admit note on the psych ward for the psych chart. A copy of the PEC and the CEC and the original consult and progress notes are left with the medicine/surgical chart.

20. The resident is responsible for a 2 brief presentations to the attending on consultation topics during the rotation.

The resident is expected to bring a DSM IV-TR, reflex hammer, and either a PDA with Epocrates or drug interaction tables daily.

CONSULTS DURING WEEKENDS

Consults received during weekend should be signed-out to the subsequent weekend resident and to the consult resident on Monday morning. (for example; resident sees a floor consult on Saturday; then that resident tells the Sunday resident on call, and then the Sunday resident on call will tell the consult resident on Monday).

Consults must be seen on weekends and be seen by faculty on call that weekend.

PEC/CEC or JC patients and any problematic patient must be seen daily during the weekend/holiday by the resident, and not just the student.

EDUCATIONAL PHILSOSPHY

The educational philosophy of the C-L rotation is that the resident should be able to teach basic mental status examination, psychiatric history taking, and development of a differential and descriptive diagnosis to lesser-trained people such as medical students. At this stage, the resident should be a master of these skills and focus on the development on case formulation and treatment strategies based on understanding of the patient's biological and psychological characteristics. The resident should be able to recognize ego-defenses and personality structures in patients and use this knowledge to formulate treatment plans.

Residents should also be able to formulate treatment plans across settings that are from a medical/surgical setting to an inpatient or outpatient setting.

Included with this memo are copies of pages 751-757 of the DSM-IV, the section on Defensive Functioning. The residents should familiarize themselves with these terms and be able to discuss them in the evaluation of their patients on the C/L Service. In addition to familiarizing themselves with the DSM-IV Defensive Function Scales, I highly recommend obtaining the book, "Psychiatric Secrets" by Jacobsen and Jacobsen. I suggest reading and becoming familiar with the questions and answers in the basic chapters 1-4, 9, 10-25, 28, 29, 31, 32 and 34-39. Chapters 41-53 are recommended for child and adolescent patients. Chapters 61-563, 68 and 70-75 are recommended for specific C/L psychiatry topics. I will expect the residents to use these questions to teach students while on the C/L service.

Included with this orientation page is the orientation for medical students so that you are familiar with the expectations of the medical students.

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Emergency Psychiatry Service Overview

Staffing

The Psychiatry Crisis Unit is on the third floor in the O-wing (over the Emergency Department) accessible via the elevator near the Emergency Department. There are three residents on this service: two Psychiatry Crisis Unit (PCU) residents, and one night float resident. The first PCU resident is on from 8AM to 5PM. The second resident is on from noon to 8PM. The night float resident is on from 8PM to 8AM. The two PCU residents rotate shifts, to get equal time on each PCU rotation. The resident will be assigned for a one month rotation during his PGY-I year or PGY-II year. Typically, two PCU rotations and two Night Float rotations are assigned. PCU rotations can be sequential but Night Float rotations cannot be back to back. An attending physician is on service at all times, and rounds every morning at 8:00am. Medical students rotate through the Emergency Psychiatry service as well.

Scope

The PCU residents also serve as the outpatient consultation and liaison service to all outpatient clinics, including the Labor & Delivery clinic on the 4th floor of the hospital, as well as the Feist-Weiller Cancer Center (the Hemodialysis clinic is covered by the inpatient C&L service). We routinely handle consults from Pediatric clinic, Internal Medicine clinic, and Family Medicine clinic. There are some situations where a consult from these clinics requires the resident to go there and evaluate the patient, and others where it seems obvious that the patient needs to be emergently committed to the PCU via the ED. Clinical judgment and discussion with the attending physician is advised.

Day call residents who admit patients during the day to teams may be called for clarification of orders. However, any other subsequent change in the new patient must be handled by the resident on the treating team.

Patient Hand-Offs during Sign-Out

Residents going off-service must go through sign-out rounds with the resident coming on service. It is the responsibility of the residents changing service to communicate directly with each other for sign-out of ALL patients; sign-out must occur even if there are no patients. The patients in the PCU who have already been worked-up and are awaiting a bed must be checked out to the oncoming resident and a brief description/scenario must be given for ALL patients.

Logging of Patients for Census and Patient Logs

All patients in any location, whether ER, PCU, clinic, and including phone calls from outside the institution, must be logged in the Resident Patient Logbook/Daily Census Log. Please provide as much information as necessary about phone calls. Any admits, discharges, or changes to meds, labs, etc., must be updated in the PCU Census. Patient Evaluations The resident will evaluate the patients referred for emergency psychiatry evaluation after medically cleared by the ER Physician. Please see the Medical Clearance Checklist for details on who can be admitted to the PCU from Triage and who requires further medical clearance, and who requires direct admission as they cannot be safely cared for in the PCU. The resident will interview the patient, obtain information from the old chart and/or other sources as necessary in order to complete an evaluation. The evaluation will be documented in the EMR, and will include a chief complaint, HPI, past medical history, past psychiatric history, social history, mental status exam, as well as pertinent lab and/or physical exam findings, along with a diagnosis and treatment recommendations.

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If the resident decides the patient may be discharged, the case will be discussed with the attending on-call, and reviewed in morning rounds. If the patient is admitted to the PCU, the resident will be responsible for presenting the case in morning rounds. The resident is asked to see the patient within approximately two hours. All patients in the PCU must be rounded on every day, and have a daily note written. Night Float The night float resident has in-house call Sunday through Thursday (8pm-8am) for one month. Typically two months of this service are required, but they cannot be sequential. Night float rotation is done during the PGY-I and PGY-II years. The night float resident is excused from all daytime responsibilities. Psychiatry faculty covering the ER will provide brief lectures and feedback sessions during rounds in the morning. The night float resident covers consult calls from the ER and medical floors, as well as tending to any needs of the 10th floor psychiatry inpatient unit. The night float resident will meet with the outgoing resident when they begin their service for patient hand-off during check-out rounds, and will also meet with the oncoming resident at the end of their service for same. Check-out rounds in the morning are staffed by the attending physician for education, patient care, and resident supervision, and the full treatment team is present during weekdays. Any night float resident may contact the upper level resident who is on back-up call with any questions or concerns. The night float resident will also contact on-call faculty for any case discussion, possible discharges, or questions/concerns.

PCU Resident Handbook for EPIC

Don’t Panic!

This guide was created to help medical students/interns/residents. If you have questions, please get your upper level and if no one is around, call someone. We have all been there and if you need help, most everyone will be willing. When in absolute doubt, call Dr. Patterson (He is always available).

Getting started

On either of the frequently used computers in the doctor’s office, you will find a link to Citrix application. Double click on it and follow the log on instructions using your email username and password. You should then select “EPIC Production”. It may take a few moments for the program to launch, but then you should log in again with your email username and password.

Visualizing patients

After you log into the EPIC system, under SHV Emergency Dept, you should see the “ED track board”. Along the upper portion of the screen about 2-3 inches below the upper rim, there are several buttons for you to choose from including a “PCU” button on the right side (in between Trauma and Off the Floor).

Click the PCU button to see all of the patient’s in the PCU currently. You will see their Bed numbers, name, age, complaint, triage’s acuity rating (usually orange 2 or yellow 3), their total time in ER, and lab status.

If you click on a patient, there will be a frame at the bottom of the screen with multiple tabs or buttons. The most important of these is the “results” and the “facesheet” buttons. If you do not see the facesheet button, then there will be an arrow button with a menu that will come up with it as an option. If

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you are trying to preview a patient’s story or information prior to evaluation, you may want to click on the “All ED Notes” button and scroll through the reports there.

Near the PCU button, from above, there are other buttons that will allow you to see a patient who is in another part of the ER. WHEN you are called about a patient, you should probably go to their area of the ER (e.g. “Forties”) and find them. From there you are able to access the patient’s information as above and can review any results or findings that might have been left out of your “check out” by the ER. It will also allow you to review any vitals or trends in the patient.

Chart Reviewing

You can open a patient’s chart by double clicking on the patient’s name (or line). This will take you to a screen with default “psych documents” tab opened. You will notice that there are multiple buttons in the left hand column (Chart review, results review, snapshot, review visit, orders, discharge, admit, and psych documents). If you do not see these buttons, or there are more than these, you should check your context and make sure that you have chosen “SHV Emergency Dept”.

If you are wanting to review labs, you should click the “Results Review button”. This brings you to a menu with data range for you to choose. Select whichever you are interested in viewing and click accept in the lower right hand of that screen. In order to scroll easily, you should click somewhere on the right side of the screen in order to move the cursor to that frame. Use mouse wheel as you would normally. In the left hand frame, there is an outline of results including laboratory results, radiology/imaging, and “others”. Click on the respective button to access your desired results.

If you want to see the imaging yourself, click radiology/imaging results. Double click on the desired study. Another window will appear and should include the report. There are other blue titles such as “Study Result” and “Imaging”. You should click on the link under “PACS images” You will have to have your PACS login and password available. Also you may also have to click to run “active X” files in order to view these images.

To view old notes, there are two options. One, you may click the “Chart Review” button in the far left hand column. This will bring you to a screen with row of several tabs (you are defaulted to “Encounters”). You should then click the “Notes” tab. In general you will see several notes but not necessarily psychiatry notes. Directly above the notes and about halfway across the screen, there is a check box with “Exclude” checked off. You should uncheck this box to reveal the psychiatry notes. It may be helpful to you to look in the “Author” column for resident/attending notes to speed up your search. Another method would be to click on “Psych documents” button in the far left hand column. As before this will bring you to a screen that has the latest documents. If the document you are looking for is not here, you should scroll to the top of the page. Underneath the blue header “ED Psych Notes” there are several buttons. The one with a yellow note pad is “Go to Notes”. Click this button.

You should be able to see multiple notes and will be defaulted to “Progress” tab. You may have to click on the tabs in order to find the note you are looking for. You will also see action buttons above the tabs such as “New Note”, “Create in Notewriter”, “Addendum”, “Copy”, etc... Once again, looking in the “Author Name” column may speed your search.

Frequently we are asked to review the patient’s facesheet. This can be done from the Trackboard, but also from the patient’s chart. In the far left hand column, choose the “Snapshot” button. You will be defaulted to the “Snapshot with Recent Visits” button. Along that same row of buttons, you will see other similar icons. There will be a double arrow to the right indicating more options. Clicking the arrows will drop down a menu. Select “Facesheet”.

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Admitting to PCU

If you are admitting someone to the PCU, this is an easy process. Usually you will be paged by the ER, “I’ve got a patient for you…” After you review the patient’s vitals, any special needs (lines, oxygen, CPAP, non-ambulatory status, etc.), and complaint, you should verbalize that you are accepting the patient “up to the PCU”. Afterwards, you MUST call the nurses in the PCU at 57601 and inform them that you have accepted the patient. “Hey, I’ve accepted Mr. Smith in Bed 44 from the ER. Thank you.” Nursing staff will facilitate transfer and your responsibility is complete.

Writing a note

After evaluating the patient, find his chart in the track board in the “PCU”. You should double click to open the chart. You will see a blue header “ED Psych Notes”. Underneath the header is “Create note”, drop down menu, “Go to Notes”, and “refresh” buttons. Click on the drop down menu. Select “Blank Note”. You will be brought to a screen for creating your note. In the “Service” search box, type “Psy” and press the enter key. The date and time should already have been filled in for you. Underneath the “Service” search box, you will find the “Cosign Required” box unchecked. It is very important to make sure that this boxed is checked before you sign your note.

In the text window, type “.psypcu” and a list of templates should appear. Currently we are using the “PSYPCUINITIALEVAL” template. Double click the template and it should appear in the text window. Press the F2 key to go to the top of the page and begin to fill out the template wildcards and drop down menus. You may also go in and free text whatever may be missing.

You may have a handy panel that is opened when you first open up your blank note. On the right hand side of the screen there should be an open panel with several tabs along the top like “triage”, “Results”, and “Snapshot”. If you do not see this panel, there should be a double arrow pointing to the left on the far right hand portion of the screen, midway down the screen. Click that button to open the panel. TIP: If you want labs quickly, you may consider clicking your right hand panel “Results” tab. You can then copy and paste all of your labs from there by right clicking the panel and choosing “copy”. Then place your cursor in the text document and right click. Choose “paste”.

If you do not see this template, you should first double check that it is typed correctly. You should contact an upper level or previous PCU resident to share this template with you and your medical students.

If you need to share this template with others, please click the “Epic” button in the upper left hand corner of the screen. Scroll down to tools. Select the “My SmartPhrases” tool. You will see a list of all of your available Smartphrases. You are also presented with multiple action buttons. On the far right is the “search” button. Click this button and type “psypcui” and search. This should bring up the correct Smartphrase. You may right click and choose “share” or you may click the share action button.

In the “where” box, the “user” tab will be opened with a box to insert names. You may type in the person’s name if you are unsure of their user ID. Otherwise, you can simply type in their user ID. Then click accept after your list is complete. NOTE: The receiving person will have to log completely out of “hyperspace” in order for those templates to come into effect.

If you are writing a note and have to leave, you can “Pend” the note by clicking on the “pend” button in the lower right hand corner of the screen. This allows you to save and edit the note later. TIP: If you are writing a note and Epic servers go down/reboot/lose connection, you WILL lose all of your work unless it is saved by being pended/signed.

When you are attempting to do a note on a patient that has been seen by a medical student, you MUST see the patient yourself. After your evaluation, you should find the patient’s note written by the medical student (presumed to be done with the proper template set-up) by the instructions above. You

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may copy their note by highlighting and then right clicking to choose “copy”. You then start a “blank note” as you would for your own note. Then you “paste” the note into your text window.

Make sure that you look over the material and make corrections or additions as appropriate. Remember, this is a tool to help you get work done and teach medical students, not a way for you plagiarize and blindly sign.

When your note is complete, you should click the “Sign” button at the bottom right of your screen to finalize your note. You can still edit your note until it is cosigned by an attending.

Writing orders/legal status

When you are trying to get your orders done, you should go to the “Orders” button on the far left of your screen. From here you will see “order sets” and “orders” along the top of your screen. If you do not see previous orders, click the “orders” link to open the interface with current/new orders. In general, you will only use the “orders” link to take care of your patients.

To get the majority of your orders taken care of quickly, you should scroll down to the red header “ED Orders”. You can also click the “new orders” button on the right of the screen to navigate there as well. You should see a search bar with two buttons on the right, “search” and “Pref List”. Click the “Pref List” button to bring up the “Preference list browser.” Near the top of this window, you will see 3 tabs called “Browse”, “Preference List”, and “Facility List”. Underneath those tabs you should see an unchecked box with at star, “Only favorites”. Please check that box.

If you have not added any orders to your favorites list, then you should default to “Psychiatry Prefs (Orders)”. From here to the bottom of the scrollable window, you will find most if not all of the default labs, meds, precautions, and diets you will need for your patients. Note: There is no detox precaution at this time. Also, if you are trying to order an RPR, search for “treponema” and you should find the correct antibody lab. Legal statuses are searchable by their initials (e.g. FVA, PEC, JC, etc.).

Select the boxes for the options you want and click accept.

Discharging

If you want to discharge a patient, you need to prepare by getting some basic information. You need to have where they are going, who they are going to follow with, what medications you want them to leave with, what pharmacy they are going to go to, and their final diagnosis. When you know or have all of these things together, you will be able to discharge your patient quickly and efficiently.

Click on the Discharge button on the far left column. This will bring you to a screen with several blue bold headers. You will start from the top and work your way down. Click “Disposition” header to open the window. You can choose what your final disposition will be for the patient: “Discharge”, “Transfer”, “Elopement”, and “Expired”. Each of these has an open circle where you can click to choose your disposition. Note: If there is text in the field that is left over from the ER, you should delete it before making your choice. Otherwise, you may delete all the text and select another choice and reselect your original choice to bring up the proper text for your disposition. After you have filled in the proper information, you can click the “Next” button in the lower right hand corner of that window or press the F8 button to continue.

For Follow up, you will generally click the “Other” button in the “With:” row. You may then free text your patient’s follow up as well as enter in comments. When you are done, you can continue on to “Clinical impression”.

“Clinical impression” is in essence the problems that the patient is being seen for during this visit. You may change these, delete them, add new ones, or add them to the patient’s problem list from this interface. Adding impressions is in the upper left hand corner. On the far right of the window is the “delete” button. Directly to the left of the “delete” button is a small icon/button that will add that

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impression to the patient’s problem list. Keep in mind, any complaint on the Problem List can be seen by anyone who is providing care to the patient or accessing their chart. When complete, you may then proceed to the “Med Reconciliation” header.

When you first open this window, you will notice a listing of the patient’s medications with two options on the left side of the screen, “No Rx” and “Prescribe”. You need to go down the list and click an option for each medication. At this time, there is no shortcut to get through this. When you get to the bottom of your list, you will see a light colored header, “Prescriptions/Referrals”. You can use the search bar or click the “Pref List” button to find the prescription you want for your patient. Make sure you choose the correct formulation.

If you are going to write a prescription for the patient by hand, you should edit your prescription in the computer by clicking on the blue text beneath your medication to open the interface. In the “Class:” row, you should choose “Print”. If the patient is receiving samples, you should choose “No Print”. If you are e-prescribing, then you should leave the class as “Normal”.

Underneath the “Prescriptions/Referrals” header in the left hand corner you will see a “Pharmacy” button. There will also be some text to the right of it to display the status. Click the “Pharmacy” button to bring up the “Pharmacy Selection” window. You may search with the upper search bar or with the search tab. There is a default checked box in the search tab interface called “Patient and clinic’s nearby ZIP codes. This may help you find your desired pharmacy significantly faster. After finding the correct pharmacy, click the “Accept” button. You should now see your patient’s pharmacy listed in the text to the right of the “pharmacy” button. When this is complete, move on to the “Discharge Instructions” header.

Discharge instructions

When you click on the “Discharge Instructions” header, it will open a text window. Here, you will use templates provided to us by Dr. Patterson. Every patient will need “.pcuall”, instructions for their diagnosis, follow up instructions, and any other instructions you feel are appropriate. You can quickly find a patient’s diagnosis instructions by typing “.pcud” which will bring up a list of all diagnosis instructions. You can find the referrals/follow-up instructions by typing “.pcur”. If none of these are working for you, then make sure that someone has shared them with you. In general these have been shared with all residents in the Psychiatry residency. You may need to share them for new interns. Once that is complete, you can tell Karen or your nurse to print out the patient’s “After Visit Summary” or AVS. These function as discharge instruction paperwork for your patient. STOP here. You are done!

Transferring Patients from PCU to 10th floor.

In order to transfer a patient from the PCU to 10th floor you need to change your context to “SHV PSYCHIATRY CLN”. Beneath the “Epic” button in the top left of the screen are four tabs. The second one is the “Patient’s List” tab. Click this tab to show the outline of lists. Double click the “*SHV Hospital” folder. Second to last on that list will be the “Unit” folder. Double click that folder. You should be able to see a list of all of the wards of the hospital. Click on the emergency list. This will open all of the patients who are in the ER. It may be useful to sort by name if the ER is especially busy. You should double click your patient to open the patient’s chart.

You should be seeing the default “Patient Summary” button. On the far left hand column click the “Admission” button. In the next column you will see “Med Rec-Sign&Hold” directly to the right of the “Admission” button. Click that link to open a series of windows starting with “Review Current Orders”. You will want to click the “Continue Unselected” button in the upper right hand corner of that window. Then you may click the “next” button.

“Review prior to admission medications” is next and at the bottom left hand corner you will find the “Mark as reviewed” button. Look over these medications and click that button as appropriate. You

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should then proceed to “Reconcile Prior to admission Medications”. You are then presented with the option to reorder, don’t order the medications for the patient. Choose “Don’t order” for all of the medications as we are only going to continue what was started in the PCU.

When you get to the “New Orders” menu, you should have a red stop sign next to a default “Admit to inpatient from ED” order. If you do not see this order, you need to search for it via the search bar. You will have to click the blue link beneath this order to put in the proper information. At this point you may need to call 10th floor (56977) and ask who the patient will go to. Otherwise you may place the patient with any team and they will sort it out upstairs. Accept this order when you are through putting information into the slots.

You will then need to go to the yellow “best practices advisory” by checking the box for “Reason for no VTE prophylaxis at admission”. You should then click the accept button in the bottom right of the screen. You will see three options to answer. In general you will choose “Low Risk for VTE”. Once complete, look to the upper right hand corner and click “5. Summary”. You will have the chance to review your orders before you sign off on them and finalize. In the bottom right hand corner will be the “Sign & Hold – Will be initiated by receiving unit” button. You are then done and may return to the Emergency Dept context to continue your work.

Transferring patients from the floor to 10th floor is still shaky at best. There will HAVE to be a PAPER Admission approval form done for the patient. 10th floor still has these papers, but they have been eliminated from the ER/PCU.

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On-call Checklist (print this and keep in your pocket!):

On call (night float/weekend/holiday) duties: When coming on:

1. ER consults

2. Inpatient Consults

3. Care of Patients in PCU and Inpatient unit

1. Get a copy of the PCU census from the nurses’ station

2. Patient HANDOFF: Get a brief history of each patient in the PCU from the resident you are relieving

3. Find out which patients need to be evaluated

4. Make sure of what needs to be done for patients that have NOT been fully evaluated – who needs labs, who needs orders, who needs a PEC, etc.

5. Ask specifically for any problem patients in the PCU or on the 10th floor

6. Ask if there are any beds on the inpatient unit, and which patients are to get those beds

7. Get the pager and keys!

1. ER Consults

1. You will be consulted by either the ER physician, or RN at Triage. Get a brief history, vital signs, and any possible medical issues

2. If the Triage nurse is calling you that means that the patient should meet criteria for medical clearance at Triage. Ensure that this is so (see Checklist)

3. From triage, you may request labs for further, rapid medical evaluation in the PCU: UDS and serum ETOH almost always, and any other labs you feel may be indicated (e.g., blood glucose if diabetic, etc). If you are going to look at electrolytes, always get a CMP rather than BMP because we need to know about LFTs.

4. If the ER MD calls you, then the patient was likely NOT medically cleared at triage, and was then further medically cleared by the ER MD. Inquire as to what was required to medically stabilize the patient, and ensure the patient is now medically cleared. By this time they have drawn blood and urine (at least for serum ETOH and UDS) and so you may ask them to send further labs as needed FOR FURTHER AND MORE RAPID EVALUATION IN THE PCU (not for “medical clearance”).

5. If another service calls you from the ER with a

When patient arrives

1. Complete EMR record in EPIC.

2. Get collateral history from family or friends

3. If you feel the patient is safe for discharge:

a. Discuss the case with the attending

b. Discharge using EPIC, using appropriate referrals and prescriptions as discussed with your attending. This typically includes one or more diagnosis education documents so that the patient knows what they have and were treated for, and one or more referral documents so they know where they are being referred to. Also include details about their prescriptions if they were E-prescribed.

c. Appointments (nurses can help with this, but be sure it makes it to the social workers’ office): If referred to primary care, counseling or to substance abuse, the patient needs to call for an appt. Please send an EPIC consult to the appropriate Primary Care service. If referred to a specialist (e.g., Neurology) the patient needs to have a consult sent. If this is done after hours or on weekends, please notify the Case

v.120611

9

request for evaluation, be extra careful! That means that the patient has failed medical clearance at Triage, and a medical service consulted to evaluate and medically stabilize the patient. If they are calling you, that means that either: a.) The patient is going to be admitted to a medical service, and they want to consult Psychiatry CL service early, OR: b.) The patient has been deemed medically stable and not meeting admission criteria, but does need psychiatric evaluation. In the latter case, be VERY CAUTIOUS.

6. Get the patients name and MR number

7. Request the patient be sent up to the PCU if medically stable. DO NOT REFUSE PATIENTS. If you feel uncomfortable accepting a patient that you feel is medically unstable, tell the physician that you must call your attending and discuss the case before you accept. Then call your attending and discuss the case. IF your attending feels that the patient is not medically stable, that needs to be discussed at the attending to attending level only.

8. Notify nurses that you have accepted a patient.

Manager by Email or EPIC message that the patient needs referral or review for needs.

9. If admitting:

a. Patient must have a legal status. Most patients in the PCU need a PEC, but if they choose to stay they can sign a FV.

b. Write admit orders in EPIC

c. Discuss with attending or backup resident if you have any questions.


***The primary service is ALWAYS responsible for writing their own orders and PECs (but often need help with the latter)

New Consults Old Consults

1. ER Consults always take priority over new inpatient consults, unless it is an emergency (eg acute delirium, patients that have questionable capacity attempting to leave AMA)

2. You may be able to do some management over the phone, but it is ultimately your responsibility to see the patient when you are on call

3. Do a chart review to understand what has happened up until now, and to get a full understanding as to why you were consulted

4. Do a full H&P, documenting current meds and labs (.meds and .labs), in EPIC.

5. Call the attending with any questions regarding management and recommendations

6. Let the on-coming treatment team know that you saw a new consult during check out rounds AND via message, so that they know to staff it later or the following day.

1. If you are on call 8a-8p on a weekend or holiday, you will be responsible for writing daily notes for patients that are PEC’d or unstable; a list of these patients should be left by the C/L resident.

2. If the primary service calls with a question, do your best to handle it over the phone; if necessary, go see the patient and write a note

3. If the primary service calls you asking you to admit the patient, kindly explain to them that all beds are full, but if the patient is medically stable, you will put the patient on the list for admission. That list is kept in the PCU, in the back office. Explain that patients are admitted to the 10th floor in the order they are on the list.

v.120611

10

3. Care of Patients in PCU and Inpatient Unit

Issues, issues, issues Transfer of patients to the 10th floor

1. Usually can be handled over the phone

2. Often, you will just get requests for prns or to renew an order that has expired

3. If a medical issue arises (ie, pt has chest pain, fell, etc), see the patient, write a note detailing what your plan is; call medicine for any questions, or if you feel a consult is necessary

4. Be sure you are aware of and know how to consult the START team for urgent medical requirements, and how to call for a code in emergent cases.

5. You are responsible for overseeing the transfer of patients to the 10th Floor from the PCU and C/L patients

1. From PCU

a. Follow the new EPIC protocol cheat sheet in PCU

2. From C/L service

Consult Guidelines for On Call Admits

1. Consult patient to be admitted to the inpatient unit are usually chosen by the consult team. This list is to be updated daily with sign out to the PCU team. Consult resident is required to call the inpatient unit and inquire about the number of beds so that he/she knows when their patient is going to be admitted.

2. In general, it is the resident and attending physician’s judgment about which patients are suitable for the inpatient unit. General contraindication include but are not limited to:

a. Active delirium, no matter the cause, including alcohol

b. Catheters, iv lines, Foleys, insulin pumps that cannot be turned off, continuous oxygen requirements.

c. Severe ambulation issues. d. Unstable vitals e. Patients cannot go directly from ICU to the

inpatient unit, require at least 24 hours of stability.

3. The service that the patient is previously on is required to discharge the patient with a complete discharge summary and recommendations for medical care on the inpatient unit. Usually notified of this requirement by the day team.

4. Once a patient is deemed safe for admission, the

following needs to occur: a. A paper admission approval form needs to be

delivered to admitting or given to the floor nurse.

b. Any legal papers that the patient has are to accompany the patient to the inpatient unit. This includes PEC, CEC, JC.

i. The above is usually done by the consult resident during the day,

c. A transfer not is to be written: includes CC, HPI, PPH, PMH, PSH, Meds, Allergies, FH, SH, Hospital Course, vitals, physical exam, MSE, Neurological Exam, Assessment and

v.120611

11

Plan. Usually done by day team. d. Orders for the inpatient unit need to be entered

by the on call physician. i. Usually done as a new admission,

using the admit to psychiatry tab, ii. Requires one to call and find out which

attending will be taking the patient. iii. Use admit to psych order set. iv. Make sure patient has PRN

medications v. Make sure that diabetic patients have

their medications restarted, blood glucose checks done BID, and have sliding scales if necessary

vi. Make sure appropriate hypertensive meds are restarted.

vii. Make sure that antibiotic meds if necessary

viii. Follow up any anti seizure medications that need levels

ix. Follow up any lithium levels as these are often missed by medical service

x. Make sure all appropriate titers were drawn and reviewed.

5. Notify Consult team by email when other services call

stating patient is medically stable.

Page 1 of 5 Guide to the Rural Community Psychiatry Rotation, HPLMC

Guide to the Rural Community & Forensic Psychiatry Rotation, LSUHSC Huey P. Long Medical Center

Michael Su, MD & Joseph Guthrie, MD

LSUHSC-S Dept. of Psychiatry

Last Updated: June 2010

Dear, Residents:

The Rural / Community Psychiatry rotation in Alexandria, LA is an excellent opportunity to gain confidence in the evaluation, treatment and management of acute psychiatric inpatients. You may also gain further experience in Emergency and Consult-Liaison Psychiatry. It is our hope that this document will help to prepare you prior to the rotation and serve you well during your stay. Always feel free to contact other residents who have come before, chief residents, and the attending whenever necessary. We hope you have an enjoyable experience at Huey P. Long Medical Center.

GOALS

1) To enable the residents to have a basic understanding of the management of chronically and severely mentally ill patients in the public sector

2) To enable the resident to understand the need for public sector psychiatrists’ involvement in mental health policy making

3) To prepare the resident to perform psychiatric evaluations and work with a treatment team to develop treatment plans

4) To comprehend the administrative organization of the state mental health system by working in the system

5) To learn the subtleties of the practice of inpatient pharmacotherapy

6) Introduce resident to Forensic Psychiatry

7) Allow supervised evaluation of patients for civil commitment

8) Observe or participate in courtroom testimony from or as an expert witness


OBJECTIVES

Knowledge. The resident will demonstrate knowledge of:

1) The resident will demonstrate knowledge of: Descriptive psychiatry including description of various clinical syndromes per DSM-IV

2) Develop a differential diagnosis of psychiatric syndromes

3) Indications, contraindications, presumed mechanisms, dosing schedules, and side effects for common psychopharmacological agents

4) Community resources and principles of systems based care

5) Psychiatric economics, patterns of private and pubic funding and reimbursement

6) Documentation and procedures of involuntary commitment

7) Laws of clinical responsibility

8) Principles of informed consent, confidentiality, privileged information, and exceptions to confidentiality including Tarasoff law

Skills. The resident will be able to:

1) Perform evaluations of patients who present to a community hospital with a wide range of typical problems in persons of diverse cultures, ethnic and economic backgrounds

2) Become conversant in choosing the best treatment options available for each patient based on consideration of these variables

3) Manage and follow-up of assigned long-term chronic psychotic patients, become an expert in the use of all resources available to him/ her medically, and in the community, for the benefit of the patient. This will necessarily involve the development of effective leadership skills in coordinating efforts of others in the service of the patients

4) List some of the issues in the practice of inpatient pharmacotherapy including its effect on psychotherapy, patient compliance, dosage regulation, and the management of side effects

5) Learn techniques of crisis intervention in an inpatient, consult, or emergency setting

6) Participate effectively as part of a treatment team and direct such a team

7) Demonstrate familiarity with community resources available in the community

8) Discuss and/ or demonstrate clinically his/ her understanding of the psychiatrist as consultant to the community


Attitude.

1) The resident will be empathetic, compassionate, open, and nonjudgmental

2) The resident will demonstrate appreciation for sociocultural and socioeconomic issues

3) The resident will show appreciation of principles of preventive psychiatry at the community and clinical levels

4) The resident will show sensitivity towards problems of specific ethnic and underprivileged populations

5) The resident will maintain awareness of counter-transference issues in dealings with forensic population and be sensitive to its impact on therapeutic relationship

6) The resident will interact in a direct and non-threatening manner

GETTING STARTED

1.) Be sure to fill out the appropriate travel pre-approval forms with Theresa in advance of the rotation.

2.) Call Dr. Hanna or Dr. Boppana when you arrive at the hospital. 3.) Get 2-West Inpatient Psychiatry Unit keys and pager from the operator room at the lobby. 4.) Go to Medical Staffing Office and ask for Ms. Sandra (located in trailer next to Doctor’s Parking

on the far left side of the hospital) 5.) Then go to Human Resources Dept. office to get badge (a two story building near the main road,

when you walk in the front doors, take the spiral walk-way to the 2nd floor and get your picture taken).

6.) The unit is on the 2nd floor of the hospital. There is a set of double doors directly in the middle of the hospital and an Access Door with a camera above it—always use this access door. The nurses will show you the Work Hours Log sheet and show you around the unit.

7.) Call the administrator’s secretary and request the Teleconference Room for lectures.

PARKING

1.) We can park next to the hospital at the signs marked Doctors Parking or along the yellow line. If these are full, feel free to park in the larger lot.

2.) No tag needed per se, but you might want to let security know your vehicle make/ model/ license plate for convenience.


DAILY ROUNDS

1.) Arrive at 08:00 at prepare for the day’s discharges, make preliminary calls, and other pre-rounds business.

2.) Rounds with the treatment team usually start at 08:30. Each social worker has assigned patients, so we usually see all of one group, then the other.

3.) There are a total of 16 patients on this unit. Dr. Hanna, Dr. Boppana, and Dr. Stevens are the supervisors.

4.) Be sure to break for lunch as the cafeteria does close then return to finish rounds and dictate discharge summaries.

5.) On new patients, be sure to fill out the initial assessment (may be dictated) and treatment plans, AIMS, and any orders.

6.) If beds are available, review the patient information packets and decide which patients are appropriate for admission to the unit.

7.) Fill out the billing slips each day (front of chart). 8.) Off-duty at 17:00 daily and 18:00 on Fridays. Check out with the weekend doctor on Friday

afternoons. 9.) Speak with Drs. Hanna and Boppana regarding their schedules at the start of the rotation.

LEGAL ISSUES

1.) Monitor Legal Status for expiration. File notes to court for JC by faxing signed note to Michelle Brown, hospital attorney, at 318-222-0065 (Office Phone# 222-0066).

2.) If assigned, perform Physician’s Report to Court evaluation on the day of or after you are served with JC papers and give to the social worker. You can dictate the note by using Work Type #7. Just be sure to fill out the carbon copy form by hand.

3.) Court is held on Thursdays at 13:30 in the afternoon at the courthouse downtown about 2 miles from the hospital.

EMERGENCY ROOM & CONSULTS

1.) Once caught up with daily routine work, contact the Emergency Dept. and see if any PEC/CEC patients need to be evaluated and make recommendations to start medications.

2.) There is a drawer in the glassed-in area labeled “PSYCH FORMS” that contains most anything you need (except order forms). The nurses are very helpful with everything else.

3.) ICU will call with other consults periodically, though not often. 4.) Be sure to fill out a billing sheet for the ER/C-L visit and give to Dr. Hanna.


LODGING

1.) Make reservations at the Alexander Fulton Hotel in advance of your rotation. There is a physician’s rate of $30 per night.

2.) Residents will be reimbursed for 5 nights per week (Check-in Sunday, Check-out Friday), so save your receipts.

3.) Make use of the complimentary Wi-Fi connection, Exercise Room, and Continental breakfast each morning.

TRAVEL

1.) Current policy is for residents to use their personal vehicle to get to and from Alexandria. 2.) Keep your gas receipts and log your mileage for reimbursement at the end of the rotation.

MEALS

1.) Lunch & Supper are provided in the hospital cafeteria. Sign your name and initial on the clipboard. They no longer serve breakfast in the cafeteria. Meal times are 1130-1PM and 4:30-5:30PM for lunch and dinner, respectively.

2.) Critic’s Choice is a good sandwich place near the hospital. Otherwise, continue down Jackson Street (take a right from the hospital) and much can be found at and around the Super Krogers. An alternative is to go down 28-East for the usual fast food places.

3.) Vegetarians: The cafeteria has a lunch fruit or veggie plate. Also, Little Greek on Jackson St. has a good vegetarian selection.

4.) At this time, food is not reimbursed.

END OF ROTATION

1.) Hand in the work hour log sheet 2.) Also, get signatures from departments to clear you out (a form from Miss Sandra). 3.) Give keys and pagers back to the operator. 4.) Sign out to the resident for next month by e-mail or phone.

We hope you’ve had an enjoyable, educational rotation. Please forward any necessary additions, deletions, or suggestions for this rotation guide to the chief residents.

Psychiatry On-Call LSUHSC

Updated 6/25/2008

On-call Checklist (print this and keep in your pocket!):

On call (night float/weekend/holiday) duties: When coming on:

1. ER consults


3. Care of Patients in PCU and Inpatient unit

1. Get a copy of the PCU census from the nurses’ station

2. Patient HANDOFF: Get a brief history of each patient in the PCU from the resident you are relieving

3. Find out which patients need to be evaluated

4. Make sure of what needs to be done for patients that have NOT been fully evaluated – who needs labs, who needs orders, who needs a PEC, etc.

5. Ask specifically for any problem patients in the PCU or on the 10th floor

6. Ask if there are any beds on the inpatient unit, and which patients are to get those beds

7. Get the pager and keys!

1. ER Consults

1. You will be consulted by either the ER physician, or RN at Triage. Get a brief history, vital signs, and any possible medical issues

2. If the Triage nurse is calling you that means that the patient should meet criteria for medical clearance at Triage. Ensure that this is so (see Checklist)

3. From triage, you may request labs for further, rapid medical evaluation in the PCU: UDS and serum ETOH almost always, and any other labs you feel may be indicated (e.g., blood glucose if diabetic, etc). If you are going to look at electrolytes, always get a CMP rather than BMP because we need to know about LFTs.

4. If the ER MD calls you, then the patient was likely NOT medically cleared at triage, and was then further medically cleared by the ER MD. Inquire as to what was required to medically stabilize the patient, and ensure the patient is now medically cleared. By this time they have drawn blood and urine (at least for serum ETOH and UDS) and so you may ask them to send further labs as needed FOR FURTHER AND MORE RAPID EVALUATION IN THE PCU

When patient arrives

1. Complete EMR record in EPIC.

2. Get collateral history from family or friends

3. If you feel the patient is safe for discharge:

a. Discuss the case with the attending

b. Discharge using EPIC, using appropriate referrals and prescriptions as discussed with your attending. This typically includes one or more diagnosis education documents so that the patient knows what they have and were treated for, and one or more referral documents so they know where they are being referred to. Also include details about their prescriptions if they were E-prescribed.

c. Appointments (nurses can help with this, but be sure it makes it to the social workers’ office): If referred to primary care, counseling or to substance abuse, the patient needs to call for an appt. Please send an EPIC consult to the appropriate Primary Care service. If referred to a


Updated 6/25/2008

(not for “medical clearance”).

5. If another service calls you from the ER with a request for evaluation, be extra careful! That means that the patient has failed medical clearance at Triage, and a medical service consulted to evaluate and medically stabilize the patient. If they are calling you, that means that either: a.) The patient is going to be admitted to a medical service, and they want to consult Psychiatry CL service early, OR: b.) The patient has been deemed medically stable and not meeting admission criteria, but does need psychiatric evaluation. In the latter case, be VERY CAUTIOUS.

6. Get the patients name and MR number

7. Request the patient be sent up to the PCU if medically stable. DO NOT REFUSE PATIENTS. If you feel uncomfortable accepting a patient that you feel is medically unstable, tell the physician that you must call your attending and discuss the case before you accept. Then call your attending and discuss the case. IF your attending feels that the patient is not medically stable, that needs to be discussed at the attending to attending level only.

8. Notify nurses that you have accepted a patient.

specialist (e.g., Neurology) the patient needs to have a consult sent. If this is done after hours or on weekends, please notify the Case Manager by Email or EPIC message that the patient needs referral or review for needs.

9. If admitting:

a. Patient must have a legal status. Most patients in the PCU need a PEC, but if they choose to stay they can sign a FV.

b. Write admit orders in EPIC

c. Discuss with attending or backup resident if you have any questions.


***The primary service is ALWAYS responsible for writing their own orders and PECs (but often need help with the latter)

New Consults Old Consults

1. ER Consults always take priority over new inpatient consults, unless it is an emergency (eg acute delirium, patients that have questionable capacity attempting to leave AMA)

2. You may be able to do some management over the phone, but it is ultimately your responsibility to see the patient when you are on call

3. Do a chart review to understand what has

1. If you are on call 8a-8p on a weekend or holiday, you will be responsible for writing daily notes for patients that are PEC’d or unstable; a list of these patients should be left by the C/L resident.

2. If the primary service calls with a question, do your best to handle it over the phone; if necessary, go see the patient and write a note

3. If the primary service calls you asking you to admit the patient, kindly explain to them that all beds are full, but if the patient is medically stable,


Updated 6/25/2008

happened up until now, and to get a full understanding as to why you were consulted

4. Do a full H&P, documenting current meds and labs (.meds and .labs), in EPIC.

5. Call the attending with any questions regarding management and recommendations

6. Let the on-coming treatment team know that you saw a new consult during check out rounds AND via message, so that they know to staff it later or the following day.

you will put the patient on the list for admission. That list is kept in the PCU, in the back office. Explain that patients are admitted to the 10th floor in the order they are on the list.

3. Care of Patients in PCU and Inpatient Unit

Issues, issues, issues Transfer of patients to the 10th floor

1. Usually can be handled over the phone

2. Often, you will just get requests for prns or to renew an order that has expired

3. If a medical issue arises (ie, pt has chest pain, fell, etc), see the patient, write a note detailing what your plan is; call medicine for any questions, or if you feel a consult is necessary

4. Be sure you are aware of and know how to consult the START team for urgent medical requirements, and how to call for a code in emergent cases.

5. You are responsible for overseeing the transfer of patients to the 10th Floor from the PCU and C/L patients

1. From PCU

a. Follow the new EPIC protocol cheat sheet in PCU

2. From C/L service

Consult Guidelines for On Call Admits

1. Consult patient to be admitted to the inpatient unit are usually chosen by the consult team. This list is to be updated daily with sign out to the PCU team. Consult resident is required to call the inpatient unit and inquire about the number of beds so that he/she knows when their patient is going to be admitted.

2. In general, it is the resident and attending physician’s judgment about which patients are suitable for the inpatient unit. General contraindication include but are not limited to:

a. Active delirium, no matter the cause, including alcohol

b. Catheters, iv lines, Foleys, insulin pumps that cannot be turned off, continuous oxygen requirements.

c. Severe ambulation issues. d. Unstable vitals e. Patients cannot go directly from ICU to the

inpatient unit, require at least 24 hours of stability.

3. The service that the patient is previously on is


Updated 6/25/2008

required to discharge the patient with a complete discharge summary and recommendations for medical care on the inpatient unit. Usually notified of this requirement by the day team.

4. Once a patient is deemed safe for admission, the

following needs to occur: a. A paper admission approval form needs to

be delivered to admitting or given to the floor nurse.

b. Any legal papers that the patient has are to accompany the patient to the inpatient unit. This includes PEC, CEC, JC.

i. The above is usually done by the consult resident during the day,

c. A transfer not is to be written: includes CC, HPI, PPH, PMH, PSH, Meds, Allergies, FH, SH, Hospital Course, vitals, physical exam, MSE, Neurological Exam, Assessment and Plan. Usually done by day team.

d. Orders for the inpatient unit need to be entered by the on call physician.

i. Usually done as a new admission, using the admit to psychiatry tab,

ii. Requires one to call and find out which attending will be taking the patient.

iii. Use admit to psych order set. iv. Make sure patient has PRN

medications v. Make sure that diabetic patients

have their medications restarted, blood glucose checks done BID, and have sliding scales if necessary

vi. Make sure appropriate hypertensive meds are restarted.

vii. Make sure that antibiotic meds if necessary

viii. Follow up any drug that need levels ix. Make sure all appropriate titers

were drawn and reviewed.

5. Notify Consult team by email when other services call stating patient is medically stable.

1 Rev December 2011

Psychiatry Survival Manual

2nd Edition - 2011

http://www.lsuhscshreveport.edu/LSUHealthShreveport/LSUHealthShreveport.aspx

2 Rev December 2011

Chapter 1: Introduction A. Training Ethos B. Disclaimers C. Suggestions for this Book, Residency and Beyond

Chapter 2: On Call

A. Information Needed for Call B. Equipment Needed for Call C. Call Responsibilities D. Weekend Call Guidelines E. Night Float F. Check-out

Chapter 3: Consults On Call

A. ER Consults B. PEC’s C. Prisoners in the ER D. Child and Adolescent Consults E. Floor Consults F. Outside Phone Calls G. Transfer Calls H. Capacity Consults I. Violent Patients

Chapter 4: Admitting the Psychiatric Patient

A. From the PCU B. From the Main Hospital C. Direct Admissions from main ER to 10th floor D. Transfers from LSUHSC to another Hospital

Chapter 5: Inpatient Psychiatry on Call

A. Psychiatry Inpatient Requesting to be Discharged B. Seclusion Orders and Emergency Administration Of Chemical Restraints C. Mechanical Restraints D. Patient Search Policy E. Medical Emergencies

Chapter 6: Medical Concerns with Psychiatric Inpatients

A. Alcohol Intoxicated Patients B. Delirium C. Neuroleptic Malignant Syndrome (NMS) D. Recreational Drugs

3 Rev December 2011

Chapter 7: Legal Documents A. Commitment for Treatment B. Criteria for Commitment C. Preparation of a Commitment Evaluation D. Formal Voluntary

Chapter 8: Psychopharmacology

A. Neuroleptics (Antipsychotics) B. Antidepressants C. Mood Stabilizers D. Benzodiazepines

Chapter 10: Inpatient Psychiatry

A. Initial assessments B. History and Physical C. Mental Status Exam D. Mini Mental Status Exam E. Old Patients

Chapter 11 – Resident Resources

4 Rev December 2011

Chapter 1

INTRODUCTION

A. Training Ethos for Residents: Never prescribe or order a psychotropic medication without reading the basic material on pharmacodynamics, pharmacokinetics and clinical considerations.

1. Never write a psychiatric diagnosis without reviewing the basic definition (DSM IV-TR) and a basic discussion of epidemiology, etiology, diagnosis, differential diagnosis, clinical course, comorbidity and treatment as provided in a full psychiatry text , not a synopsis.

2. Always ask supervising faculty for feedback and suggestions at some point during a collaboration.

3. Always provide feedback and evaluation of experiences in the program through suitable channels.

4. When a faculty psychiatrist recommends a course of action which you do not completely understand, always request an explanation.

5. When there is uncertainty or doubt, always seek assistance and advice from a faculty member, or senior resident.

6. When something is said by a patient that is not clearly understood, always ask for a clarification.

7. In general, remember that you are in training, and it is always safer to take time for collaboration and consultation.

B. Disclaimers: Some of the views expressed in this manual are open to debate and do not necessarily reflect the official departmental position. Please let your best medical judgment serve as your guide. C. Suggestions for this Book, Residency and Beyond:

1. Read this book before you are confronted with the situations outlined in this book.

2. Be a part of whatever team you are working with: ER staff, evening and night nursing staff.

3. A smile and a helpful attitude will get you farther than you may think. 4. Be flexible and improvise: ask, even when in doubt. 5. Document, document, document. Especially that your faculty agrees

with the plan. 6. Use your resident backup for advice, not just another body when

swamped in the ER. 7. Internship is for getting lots of different experience. You will

definitely get this in the ER and on weekends. 8. If the ER staff trust and know you, they will sometimes get a curbside

consult instead of a full one which will save you time.

5 Rev December 2011

Chapter 2 ON CALL

A. Information Needed for Call: You always have a senior resident as backup. They must come to the PCU when you request it. Faculty must always be available for consultation. Primary call responsibilities include:

1) Care of psychiatric inpatients’ psychiatric and medical problems 2) Consultative services to other inpatient departments 3) Consultative services for LSUHSC ER physicians

CHECK LIST

1) Make sure your beeper is on, you have the PCU key, and that the switchboard is aware of any changes that have occurred.

2) Obtain a PCU census 3) Find out if there are any open beds available. 4) Find out from the person on day call if there are any patients waiting in

the ER or any patients waiting to come into the PCU. Day call resident must sign out ALL patients to you before they leave. It will be the job of the resident on-call to know everything about every patient in the PCU, and any problem patients on the floor and consult service patients needing follow-up.

5) Find out what needs to be done - who needs labs, who has labs pending, who needs orders, who needs a PEC, etc.

6) Use a log sheet for each call – document time call received and disposition. This can be as simple as a piece of paper, just write things down!

B. Equipment Needed for Call: 1. This survival manual, there is a pocket insert with all need to know information provided with this packet, have both. 2. Weekly on-call schedule, this is on www.amion.com along with all contact information 3. Patient Transfer forms 4. All patient handouts are in EPIC under the smart phrase .pcu then the specific document that you are looking for 5. PEC forms and FV consent forms, see the chapter on Legal Documents for who is eligible for each form of admission C. Call Responsibilities 1. Primary On-Call Resident

o Calls from psychiatry inpatient units o ER consults o Med/Surg psychiatry consults

http://www.amion.com/

6 Rev December 2011

o Physical exams on ALL PATIENTS o Every patient needs a legal status, whether it be a FV or PEC/CEC

2. Back-Up Resident

o Phone consultation from primary on-call resident o Help see patients in the hospital if primary resident feels overloaded with consults o Teaching

3. Students On-Call

o The students can be helpful by data gathering and assisting with patient interviews.

o Don’t forget: a resident is needed on all documents. This means that the resident also sees the patient.

o Review your expectations with all students. o Medical students are here to learn about psychiatry, not to do the work of the

resident. 4. Faculty

o Discussion of all patients seen before a disposition is made. o Never, Never, Never decide on discharging a patient without discussing it with

faculty: if the faculty on call does not respond to paging and calling, you should call one that you know will answer the page.

o Once the decision to discharge is made, by faculty, complete the proper form in epic and print appropriate patient handouts.

D. Weekend Call Guidelines: 1. Weekend call starts at 8:00 a.m. Day call ends at 8 p.m. Night call starts at 8 p.m. 2. The weekend team includes the on-call residents, medical students, and faculty. 3. Call your faculty member at the beginning of your shift to see when they want to round on the weekend as well as their expectations. 4. See weekend on-call policy to identify responsibilities of each team member. On-Call Responsibilities:

1) On Saturday, Sunday and holidays the on-call person makes rounds of all patients and writes progress notes. A progress note is needed on all patients in the PCU who have already been seen by an attending and PEC/CEC consult patients, a list of consult patients to be seen will be made by the consult resident and posted in EPIC. It should be discussed in check-out which patients have already been staffed and which have not.

2) On all evaluations, the resident should discuss with faculty, it is to the discretion of the on-call faculty member and the RTD whether this happens on morning rounds or after each patient is seen. All problem patients should be checked out to faculty immediately after being seen.

3) All residents who were on call over the weekend will meet for PCU morning rounds on the Monday after call. These take place at 8 a.m. sharp.

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4) When on call, the resident is also expected to handle any problems occurring with patients already hospitalized including seclusion, restraint, involuntary medication, medical problems, etc. He/she should follow policies and procedures for the above.

5) The on-call person is also responsible for any emergency consults for other services. These should follow the usual procedure: PGY-I’s and II’s discuss all situations with the faculty back-up. The PGY-III’s and IV’s have faculty back-up available for problem cases and patients sent home. If a patient needs to be transferred, the on-call M.D. needs to write admit orders and either complete a FV or PEC, and discuss the case with faculty.

PCU Day Call:

1) The resident will be assigned for at least 2 one month rotations during residency, and 2 night float rotations. There are two residents running the PCU Day service. One shift is 8 am – 5 pm, the second shift is 12 pm – 9 pm. Residents are asked to divide these shifts evenly amongst themselves.

2) The resident will evaluate the patients referred for emergency psychiatry evaluation after medically cleared by the ER Physician. The resident will interview the patient, obtain information from the old chart and collateral sources as necessary in order to complete an evaluation.

3) The resident will then complete a write up. The template is in EPIC, ensure that all blanks are filled. If information was unable to be obtained, write unable to be obtained due to… Do a physical exam.

4) The resident will discuss the case after his evaluation with his attending. 5) The resident is asked to see the patient within approximately two hours. 6) The PCU residents also serve as the outpatient consultation and liaison service

to all outpatient clinics, including the Labor & Delivery clinic on the 4th floor of the hospital, as well as the Feist-Weiller Cancer Center . We routinely handle consults from Pediatric clinic, Internal Medicine clinic, and Family Medicine clinic. There are some situations where a consult from these clinics requires the resident to go there and evaluate the patient, and others where it seems obvious that the patient needs to be emergently committed to the PCU via the ED. Clinical judgment and discussion with the attending physician is advised.

7) Lectures come first. They take place on Tuesdays starting at noon. This time is protected, turn in your pagers.

PCU admit criteria There is a checklist in the PCU regarding admission of patients to PCU. Certain vital sign parameters, age restrictions, medical complications prevent patients from admission to PCU. In this situation, the patient should either stay in the ER, be admitted to inpatient medicine or pediatrics, or transferred to outside hospital.

8 Rev December 2011

Medically Unstable Patients • Sometimes, patients in the PCU develop serious medical problems – i.e. seizures,

chest pain, hematemesis, etc. • You have two options:

o Call the ER and have the patient transferred back down (quicker) o Call internal medicine (or surgery, etc.) to admit the patient to their

service o In the meantime, do all necessary labs, EKG, etc. o Discuss with your attending if you are unsure what to do o Keep track of where the patient is and where they are being admitted,

and let the consult service know that they will need to follow this patient E. Night float

o The night float resident has in-house call Sunday through Thursday (8pm-8am) for one month.

o Typically two months of this service are required, but they cannot be sequential. o Night float rotation is done during the PGY-I and PGY-II year. o The night float resident is excused from all daytime responsibilities. o Psychiatry faculty covering the ER will provide brief lectures and feedback

sessions during rounds in the morning. o The night float resident covers consult calls from the ER and medical floors, as

well as tending to any needs of the 10th floor psychiatry inpatient unit. o The night float resident will meet with the outgoing resident when they begin

their service for patient hand-off during check-out rounds, and will also meet with the oncoming resident at the end of their service for same.

o Check-out rounds in the morning are staffed by the attending physician for education, patient care, and resident supervision, and the full treatment team is present during weekdays.

o Any night float resident may contact the upper level resident who is on back-up call with any questions or concerns. The night float resident will also contact on-call faculty for any case discussion, possible discharges, or questions/concerns.

F. Check-out

1. The resident who is leaving: a. Go over the PCU census, giving a brief history on all patients in the PCU

highlighting problem patients and things that need to be done. The disposition plan on all patients needs to be reviewed, as well as who has been staffed and who needs a daily progress note.

b. Check out all patients who have not yet been seen, or who are waiting in the ER.

c. Go over the consult list, report any problem patients, anyone who needs to be staffed by an attending, and all PEC/CEC patients and patients needing daily notes. Also report consults who have not yet been seen along with the time that the consult was received.

d. Check-out any problem patients on the floor. 2. The resident who is coming on:

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a. If you have a question, ask. It is your responsibility to know about the patients who are currently in your care.

b. Make a list of the things that need to be done, and complete them. c. Inform the attending who is on call that you are coming on, and ask if they

have any specific requests for how to check-out patients.

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Chapter 3 CONSULTS ON CALL

An emergent consult patient should be seen within sixty minutes of the initial consultation request. The primary on-call resident should call in the backup call resident in any situation in which ER patients or emergent consultations cannot be seen by the primary call resident within sixty minutes of the initial consultation request. Always call your back-up resident when you need help. All other consult patients must be seen within 24 hours of the initial consult request. A. ER Consults a) When you are called to see a patient inquire about whether:

o ER staff has evaluated the patient, including possible general medical conditions o If triage is calling, the patient is presumed to be medically stable, but ask

questions. o Labs have been drawn o Read the ER note if one is written

Commonly needed labs include: 1) URINE DRUG SCREEN!!!! 2) Blood Alcohol level 3) CBC 4) CMP 5) Urine/serum pregnancy test 6) Medication blood levels if applicable 7) Thyroid studies (TSH, T3, T4) 8) Hepatitis Panel, HIV, and Syphilis IgG 9) B12/Folate Sometimes you will be called to see an ER patient, when results of initial lab work are not available yet, not yet medically cleared, and old records are not available. DO NOT REFUSE CONSULT, just ask the ER faculty to do all of the above and go down to see a patient. Many times the ER will only draw UDS and EtOH. If there is no indication to the ER that the patient requires a CBC, CMP or other labs, they will not draw it, and you cannot force them to do so, unless their medical history necessitates that these labs are checked for medical clearance. b) Assessment should begin within 30 minutes of receiving the consult, if possible. Often times, the ER is doing us a courtesy by allowing us to see a patient in the ER rather than transferring them up to the PCU. For that reason, we need to see the patient as quickly as possible, as ER space is limited. After evaluating the patient, review the old chart and any labs, call faculty to review the case and make a disposition. NEVER make a disposition without discussing the case with faculty/backup.


o If patient is not being admitted to psychiatry, complete the assessment with your recommendations

o If patient is admitted to psychiatry, complete the H & P. Complete the admit orders in EPIC, and make sure that patient has a legal status.

o Always remember to document that faculty approval was obtained. B. Physician Emergency Certificate (PEC) (Involuntary Admission): The examining physician must document:

1) The patient is mentally ill 2) As a result of mental illness, the patient evidences substantial risk of serious harm

to self or others, which risk shall be specified and described on the PEC, or the patient is gravely disabled. Patient must also be either unwilling or unable to seek treatment on his own.

3) The risk of harm is imminent unless the patient is immediately hospitalized. 4) Emergency detention in a hospital is the least restrictive alternative by which

restraint can be affected. 5) See the section on the Legal Documents for specific legal definitions regarding

dangerous to self, dangerous to others and gravely disabled. Know these definitions BEFORE you check the box

*The PEC must be filled out completely. If something is unknown, write unknown. C. Prisoners in the ER

1) Unless extremely gravely disabled, patients go back to jail with treatment prescribed.

2) Ensure jail has proper facilities. (document!) 3) Send written documentation with patient’s guard telling them what to do,

especially in regards to a suicide possibility. 4) Typical discharge instructions for a suicidal patient: Discharge to jail on

suicide precautions. Paper gown, finger foods only, no sharp objects.

D.Child and Adolescent Consults in the ER o Anyone under 18 is not eligible for admit to PCU, and, therefore, must be

seen in the main ER. o After seeing the patient and documenting exam, contact faculty. o If patient needs to be admitted, they must be transferred to Brentwood,

and all transfer forms completed and faxed to Brentwood with lab results, your note, face sheet and legal document. All children must be PEC’d as legally they are unable to sign formal voluntary due to their minor status.

o After forms completed call Brentwood to initiate transfer at 678-7500 o Keep ER nurses informed as to the status of the transfer

E. Floor Consults:

o If the consulting MD claims that the patient will be sent home, remind them that the onus for the patient’s safety is on that doctor’s head, not yours. Most services do not normally discharge patients at night.


o If a consulting colleague states the discharge orders from their service are written, but the patient is suicidal, so “would you kindly come and take this patient?” then it is appropriate to remind them that you are glad to offer your service by “evaluating” this patient.

o The following are several helpful ways of wording your communication with consulting colleagues: a) Inform them in a matter-of-fact manner that an adequate evaluation

takes some time and that you recommend they not discharge the patient until such an evaluation can take place.

b) The consulting MD retains primary responsibility for the patient until you accept that primary responsibility.

c) You understand that the consulting MD was concerned enough to involve psychiatry and hope that they will therefore be willing to retain the patient long enough for an adequate psychiatric evaluation. Should this not prove to be the case, you can only hope this MD feels confident in their decision to release the patient, and is comfortable with their decision. Make sure they understand that they are fully responsible.

d) Often you can talk a medical or surgical team out of a transfer to psychiatry over a weekend, but sometimes transfer may be appropriate and should not be avoided. If there are patients awaiting admission in the ER, then transfer from a med/surg floor to psychiatry CANNOT take place on a weekend. Inform the primary team that the patient will be placed on the list for transfer to the 10th floor.

When you evaluate an inpatient, your write up should be concise, covering the following points:

1) The reason for the referral 2) The problem 3) Past medical history 4) Personal history 5) Admitting PE and lab findings 6) Your examination 7) Formulation (brief but revealing) 8) Clinical impression 9) Recommendations 10) “Thanks” and signature 11) All floor consults should be discussed with faculty and

documented. 12) Tell the primary consult resident about the patient the next day,

e-mail and written documentation is preferred. F. Outside Phone Calls:

1) Establish with whom you are speaking with. 2) Get the patient’s name 3) Obtain the number from which the patient is calling


4) Learn both the patient’s home address and his current location 5) Often, referral information is all the patient wants or needs:

o give them the outpatient psychiatry phone number o do NOT prescribe benzodiazepines and pain meds

6) Encourage the patient to come to see you in person if the problem will require much investigation or intervention.

7) Call the police from another line if you feel the patient is in imminent harm. 8) If the patient has already taken action, call 911. 9) If you feel you have questions about the phone conversation, or you’re unsure

about the disposition or what recommendations to give to the patient, tell the patient you will call them back, call faculty or your backup for advice.

10) Log phone calls. Occasionally, patients will call and threaten suicide but refuse to identify themselves. Express concern at your inability to help them. Press them for their information. Do not get drawn into extensive phone therapy. G. Transfer Calls If you are called regarding a patient transfer from another hospital: if no beds available, then do not accept transfer. H. Capacity Consults: Another consult is to “determine capacity”- usually to refuse treatment or to leave the hospital AMA. The consulting MD usually just wants your concurring opinion that the patient cannot be held against his will. Only in an emergency can anyone other than a judge order a patient to remain hospitalized. Procedure:

1) Interview the patient and perform a MSE. 2) Ask the medicine doctor who is familiar with the patient’s case (if possible) to

explain to the patient his condition, treatment options, and consequences of not consenting to treatment.

3) Ask the patient to repeat the medicine doctor’s explanation and assess their understanding of their condition.

Points to consider in formulating an opinion about a patient’s capacity: 1) Can the patient understand the nature of his medical condition? 2) Does he realize what treatment is indicated with its benefits and complications? 3) Does he realize the consequences of refusing diagnosis or treatment? 4) Does the patient use a logical, rational thought process in making the decision or

is there an Axis I diagnosis that might be interfering with # 1, 2, or 3? Not all patients who refuse legitimate diagnosis and treatment procedure lack capacity. * It is mandatory to address the patient’s suicidal and homicidal potential when considering whether to allow patient to leave or refuse treatment.


I. Violent Patients: At times you will be faced with a possibly violent patient. You need to assess the situation in order to try and predict the patient’s actions and measures you will need to take.

1) Obtain past history from the chart or the deputy 2) Look at the patient’s body language:

a) Psychomotor agitation b) Tense posture c) Pacing d) Approach / avoidance of behavior e) Loud or profane speech

3) Give yourself a clear path to the exit 4) You should show the patient respect 5) Call the patient by their last name putting “Mr.” or Ms.” In front of it. Use titles,

such as “Sir” and “Ma’am” 6) Offer a drink of water 7) If Security is not there, always call them before you need them 8) Never negotiate with the patient about whether you will call security 9) Get people to be there with you for a show of force 10) If possible, make a plan with security before entering the room 11) If the patient attempts to leave, have security bring them back to the room 12) If medication is needed, try to offer the patient some sembiance of choice:

(Would you prefer a shot or a pill / liquid?) Good choices for agitated patients:

o Geodon IM 20 mg o Ativan PO or IM o The B52 (Haldol 5mg or 10mg, benadryl 50mg, ativan 2mg)


Chapter 4

ADMITTING A PSYCHIATRIC PATIENT A. From the PCU: It is important to note that the admission policy may change in the future. Make sure that the following is completed and documented in EPIC:

1) PEC or FV form, documented in orders 2) Admission form signed 3) Complete H & P 4) Lab results if applicable 5) Admit orders including precautions and PRN meds when they get to

the unit as well as code status and allergies. 6) Generally, if a patient is psychotic or suicidal, they would not be

considered to have the capacity to declare themselves DNR (do not recuscitate). So as a general rule, the majority of patients will be Full Code.

B. From the Main Hospital: Usually not done at night. If necessary, the patient is discharged from med/surg team, and the patient is re-admitted to psychiatry with above forms in A completed. C. Direct Admissions: If there are open/available beds, patients on PEC’s, OPC’s or RPC’s are brought directly to the unit from the main ER. It is still the resident’s responsibility to complete a full evaluation similar to an ER consult. If unstable medically, call appropriate consult urgently. (This form of admission is rare) D. Transfers from LSUHSC to Another Hospital When an ER patient is determined to require inpatient psychiatric care and there are no beds available here, then the patient should be admitted to the closest facility with a bed available. PROCEDURE: After completing evaluation, call house supervisor who will check on the availability of beds at other facilities. If another facility with an open bed refuses a transfer, then complete a variance form (or tell the administration to help with such) and give to attending.


Chapter 5 INPATIENT PSYCHIATRY ON CALL

A. Psychiatry Inpatient Requesting to be Discharged You should check the status of the patient. If the patient is involuntary, then they should not be discharged. If the patient is voluntary:

1) Assess the patient for safety issues, placement issues and support system.

2) If not suicidal or homicidal, and patient is not gravely disabled, then they may be discharged. This must be approved by the on-call attending

3) If + SI/HI or gravely disabled, then have patient sign objection to FV and allow primary team to evaluate in a.m.

B. Seclusion Orders and Emergency Administration of Chemical Restraint:

o When patients get agitated and place themselves, staff, or other patients in harm they should be secluded.

o You must remember that putting a patient in seclusion is for their protection. o There must be an interview within one hour of the restraint and it must be

documented in the patient’s chart. Call your backup if needed. o In addition to this documentation, there are also orders in EPIC for Seclusion or

Restraint that must be put in. C. Mechanical Restraints:

o A mechanical restraint is anything that restricts the movement of the whole body or a portion of a body. They should only be used as an emergency measure to protect the patient from injuring self or others when other intervention strategies have been attempted and failed.

o They shall not be used as punishment or solely for the convenience of the staff. o Restraints should be maintained as long as the patient is exhibiting unacceptable

behavior that is dangerous, but must be re-ordered and re-assessed every 4 hours. Again, documentation with specific reasoning and plan must be completed within one hour. It must be dated and timed.

D. Patient Search Policy: Body searches should be performed in the ER by campus police, and patient’s belongings searched upon admit. E. Medical Emergencies: If a patient has a medical emergency it is your responsibility to assure that an adequate evaluation is performed. If necessary, call for a consult from the appropriate specialty and notify your attending of results.


The following may be helpful in certain situations, but always use your clinical judgement.

1) Chest Pain – Ddx: angina, MI, pericarditis, TAA, PE, PTX, GERD, esophageal spasm, cholecystitis, chest wall a) Obtain VS over the phone, order pulse ox and EKG over the phone, get

patients medical history from the nurse to aid in your differential diagnosis, sublingual NTG may repeat x 3 q5min if pain continues (may hold NTG for SBP<90), chew ASA 325mg, order heplock over the phone, go see the patient and review EKG, call medicine START team

Bleeding – manisfestations – epistaxis, hematemesis, hemoptysis, hematochezia, hematuria, melena, vag bleeding, post procedure, anemia.

a) Obtain VS over the phone including orthostatics, ask quantity (this is usually overestimated), order heplock if abnormal vitals or mod-large quantity or for continued bleeding, Go see patient, if significant, order CBC, PT/PTT, Type and Cross 4U PRBC, call Medicine START team.

3) Glucose: a) Hyperglycemia: use SSI, get FSBG in 30-40 mins. If FSBG is <400, may need to get chemistry and serum ketones. IF ketones + treat as DKA-call medicine if this is suspected. Need to get AG closed. b) Hypoglycemia: get VS, IV access, D50(amp) or juice, repeat prn then IVF with D5W.

4) Hypertension – is patient having CP, HA, nosebleed, MS changes, papilledema, (any signs of end organ damage), find out what patients BP usually runs. If no signs of end organ damage, control with clonidine 0.1mg, recheck BP, may need to repeat clonidine. May give at one hour intervals not to exceed 1.0mg. If w/ signs of end organ damage-call medicine START team. 5) SOB – think CHP, PE, Pneumonia, Asthma, Pneumothorax-obtain vitals, pulse ox, go see patient CXR if indicated, medicine consult if indicated. 6) Nausea/Vomiting – is patient having belly pain, when was last BM? Go see patient if needed. Can use phenergan or compazine, but remember these are also phenothiazines and may cause dystonia, may need pm benadryl or cogentin. 7) Seizures – ensure safety of patient while patient is seizing and then call

Neurology consult. If related to EtOH or Bzd withdrawal, call internal medicine. The patient will likely be admitted to the MICU.


Chapter 6

MEDICAL CONCERNS WITH PSYCHIATRIC INPATIENTS

A. Alcohol Intoxicated Patients When an intoxicated patient is in the ER, many times you will be called because the patient has expressed suicidal ideation. While these patients obviously have problems of a psychiatric nature, their suicidal tendencies and ideation often remit when they sober up. It is best to wait until the patient is sober enough to make a reliable decision about his or her own mental status before disposition is made. Unfortunately, this often is in discord with the wishes of the ER faculty, who want a quick disposition of a patient who is often unruly and persistently disruptive. There are some guidelines to use:

1. Always have the consulting MD to get a serum alcohol concentration to aid in your assessment of the intoxicated patient. If you are uncertain of whether the patient has been drinking, get one anyway. From this value and the time at which it was drawn, you can estimate when the alcohol level will be below 150 mg/dl. In general, the alcohol level should drop about 15-25 mg/dl per hour. Ask the consulting MD to obtain another blood level at the estimated time you think the level will be <150 mg/dl, unless you believe you can adequately assess the patient.

2. It is likely that a reliable assessment of a patient can be carried out when the patient has a blood ETOH level <150 mg/dl. However, this is not an absolute necessity. An assessment done before this could be argued to be unreliable, but may vary from patient to patient. The decision to assess patients with higher alcohol level is left to your clinical judgment but you cannot make a disposition before the level is below the legal limit for intoxication.

3. Intoxicated patients can be brought to the PCU as a disposition until they are sober enough for evaluation. Ensure that a complete substance use hx is obtained and if necessary proper medications used to prevent life threatening withdrawal.

Delirium Tremens Policy: It is the responsibility of the Department of Internal Medicine to care for patients with DT’s when the patient meets all four of the criteria below:

1) Has recently abstained from the chronic use of significant amounts of alcohol, or has recently reduced the amount.

2) Is disoriented as to either time or place 3) Is either hallucinating or is tremulous. 4) Has significant elevation of one of more vital signs (SBP>180mm Hg,

P> 110/minute or T>38 degrees C or DBP>100mm hg.) When a patient with DT’s is admitted to Internal Medicine, the Psychiatry Consultation Service will be glad to see the patient in consultation regarding disposition/options after the patient becomes medically stable.


Once the patient can be assessed, your evaluation of the patient should concentrate on the expression of suicidal ideation, past psychiatric HX and a chemical dependency assessment. Questions which are directed toward obtaining a chemical dependency HX are:

o Agents and patterns of use. o Date first used and date last used for each substance. o Previous periods of abstinence for each substance. o Reasons for prior periods of abstinence. o Methods used to control or abstain from use. o Past and present withdrawal symptoms. o Medical problems that may complicate withdrawal, e.g. seizure d/o. o Problems related to use. o Specific precipitators of seeking treatment. o H/O Blackouts. o Remorse. o Guilt. o Unplanned use.

“CAGE” Questions Do you ever feel the need to Cut down? Do others Annoy you about your use? Do you ever feel Guilty about your use? Do you need an Eye-opener in the morning?

* 2/4+ is highly suggestive of abuse if not dependence

If you feel the patient is not a suicide threat, encourage them to contact a local substance abuse program. The patients can usually be referred to local substance abuse programs. If you feel that the patient continues to be a threat to self, and your disposition is to admit, it is important that your admission orders contain the following:

o Order a benzodiazepine (Librium or Ativan) for prophylaxis against withdrawal symptoms.

o Order Thiamine 100 mg PO QDay o Order MVI with folate 1 PO qd o If needed place patient on suicide and seizure precautions.

B. Delirium: Delirium can be defined as: “Widespread disturbances in cerebral metabolism characterized by confusion, disorientation, short-term memory deficits and fluctuating state of arousal.” It is common for a surgeon or internist to misidentify delirium as “psychosis” or “acute onset of mental status change with agitated behavior”. You should remember that delirium is a medical, not a psychiatric emergency. Once the DX of delirium has been


made and the patient’s immediate safety assured, the possible causes of delirium should be investigated. In most cases, deliriums are caused by CNS problems, systemic problems, and/or intoxication or withdrawal from pharmacological or toxic agents. You should assume that any drug can cause delirium, so check the temporal relationship between the change in mental status and the start of a drug. Do a good review of the patient’s chart, especially vital signs, neurological examination and hospital course. The use and documentation of the MMSE (Chapter 13) can be used to follow the cognitive impairment and provide a baseline from which to measure the patient’s clinical course. Work up you should consider after seeing the patient, getting an HPI, and doing a physical exam:

o Vital Signs: Temp, BP (lying/standing if dehydration is to be ruled out). Pulse, Respiration

o Blood/Serum: BCB with MD, CMP, ammonia, RPR, thyroid function test, sed. Rate, B12, folate, HIV.

o Urine: urinalysis, drug screen, culture o CSF: culture, glucose, protein, cell count, RPR, Gram stain. o Misc: EEF, ECG, MRI, CT.

Pharmacotherapy of Delirium

o Use low dose, high potency antipsychotics such as risperidone or haloperidol. o Discharge meds that may contribute (if possible)

C. Neuroleptic Malignant Syndrome (NMS): A consult to evaluate a patient with the possible diagnosis of NMS can be one of the more challenging consults you will receive. This is because most people have never seen a true NMS. NMS is a rare condition that can occur when a patient has been given neuroleptics. NMS is a syndrome manifested by: Fever (usually > 40 C). Rigidity – Parkinsonism (refractory EPS, Autonomic instability (labile B/P, tachycardia, diaphoresis), and impaired consciousness (delirium, obtundation, catatonia). There is usually increased WBC, but the most characteristic laboratory finding is an elevated CPK. Rhabdomyolysis with myoglobinemia can be present in about 3/4 of the patients.

It should be noted that other non-neuroleptic drugs like Reglan, Asendin and Reserpine can cause NMS. Also, it may occur with withdrawal of such dopamine agonists as: Sinemet, Levodopa, Amantadine or Bromocriptine. Risk factors for NMS include the presence of organic mental disorder, agitation, dehydration, concurrent psychotropics (particularly lithium) and male gender.


In most cases NMS occurs within the first 2 weeks of initiation of neuroleptics. Progression of full symptom complex occurs within 24-48 hours of onset.

TREATMENT OF NMS Immediate discontinuation of neuroleptic and supportive care (i.e. lowering body temperature, hydration, control of B/P). You should also try to determine if other abnormalities like metabolic or infection are present. Suggested Labs: Follow CPK, CMP and Urine Myoglobin May Consider: Dantrolene (initial 2-3 mg/kg over 10-15 minutes) Bromocriptine (initial 2.5-10 mg TID, Max 60 mg/day) Amantadine (200-400 mg/day in divided doses) Ativan (muscle relaxant to decrease CPK, temperature, myoglobinuria) In most cases recommend supportive care until the faculty on C&L can assess in the a.m. D. Recreational Drugs: Cocaine: FYI: Peak toxicity about 60-90 minutes swallowing, 30-60 snorting and within

minutes IV or smoking. Adverse effects can occur minutes or hours later. Half-life is about one hour, but may be modestly prolonged with the use of ETOH. Effects: CV-multiple type of arrhythmia’s, constriction of coronary arteries (smoking tobacco can aggravate cocaine-induced coronary vasoconstriction), and severe hypertension. CNS- Anxiety, agitation, paranoia, delirium, seizures, cerebral vasculitis and thrombotic hemorrhagic stroke. Hyperthermia and rhabdomyolysis can occur. Resp.- The valsalva maneuver often used to heighten the effects of cocaine smoking may cause pneumothorax or pneumomediastinum. TX: Most of the toxicity is too brief to treat. Benzodiazepines can be used to treat the anxiety, agitation, seizures and at times hypertension. Hyperthermia can be managed with rapid cooling.

Depression/suicidal ideation is transient with cocaine withdrawal, and so SSRIs are typically unnecessary. Psychosis must be treated immediately with antipsychotics.

Amphetamines: FYI: Depending on form can be swallowed, injected or smoked. Common examples are: Dexedrine, Ritalin and ephedrine. Effects: Similar to that of cocaine, but longer in duration, lasting up to several hours. Cerebral and systemic vasculitis and renal failure have occurred. TX: Similar to that of cocaine. Elimination does require adequate urine output and acidification of urine would also assist in clearance. Neuroleptics should not be used in patients with amphetamine overdose because they lower the seizure threshold.


Opioids: FYI: The most common opioids that you will see in the ER are: Heroin, Methadone, Darvon, Demerol, and Talwin. Effects: Heroin overdose leads to respiratory depression, pulmonary edema, coma,

bradycardia and hypotension. Acute toxic effects of Methadone may persist for several days. Demerol may cause delirium. Acute opioid withdrawal is associated with anxiety, piloerection, yawning, sneezing, rhinorrhea, nausea, vomiting, diarrhea and abdominal cramps, which may be uncomfortable but are not life threatening.

TX: An initial dose of 2 mg of Narcan IV will reverse the toxicity of most opioids: if necessary, the dose can be repeated at 2 to 3 minute intervals up to a total of 10 mg. For acute opioid withdrawal clonidine may be helpful.

Typical opioid detox regimen: clonidine, motrin, flexeril, loperamide, trazodone, vistaril.

Sedative-Hypnotics: FYI: Oral benzodiazepines are rarely lethal, but they can be dangerous when

taken with ETOH or other CNS depressants. Effects: Major toxic effect is respiratory depression and coma. TX: Respiratory depression can be managed with intubation if needed. The

benzodiapine antagonist Flumazenil reverses the effects and is useful in managing overdoses, but may precipitate withdrawal symptoms or seizures in patients who have also taken seizure-threshold-lowering drugs such as TCA’s or cocaine. At that point you should treat the seizure.

Phencyclidine (PCP): FYI: Although classified as a dissociative anesthetic, PCP has stimulant,

depressant, hallucinogenic, or analgesic effect, depending on the dose and route administered.

Effects: Overdose, which can last for days, may cause psychosis or violent behavior; restraints and benzodiazepines may be needed. Large overdoses may cause coma, seizures, hypo or hypertension, and muscular rigidity accompanied by severe hyperthermia and rhabdomyolysis. Vertical nystagmus is also a clue of PCP use.

TX: Treatment is supportive, including diazepam for seizures and external cooling for hyperthermia.

Hallucinogens: FYI: Drugs like LSD or Mescaline produce a hypersuggestible state that can be

managed by providing a calm, supportive environment. Effects: Sympathomimetic effects like: Tachycardia, hypertension, hyperthermia,

papillary dilation, hyperreflexia, nausea and muscle weakness can be seen. TX: Supportive calm environment.


Marijuana: FYI: High doses may precipitate clinical onset of previously latent

schizophrenia. Effects: Tachycardia, decrease in salivation, intraocular pressure and shin

temperature can be seen. In older patients, acute dysphoric reaction, panic attacks have been reported.

TX: Usually no specific treatment is needed. Psychosis can occur and should be treated with antipsychotics.


Chapter 7

Legal Documents

A. Commitment for Treatment: Commitment requires a formal hearing before a judge with the patient having legal counsel present. These hearings take place on campus once a week. Physician’s Emergency Certificates allow a patient to be held involuntarily for 72 hours, in that time the Coroner or Deputy Coroner will evaluate the patient and make a decision whether further commitment is needed. A PEC/CEC or EC is good for 15 days starting at the date time of the initial document. During that time, the patient’s status must become voluntary, commitment proceedings initiated, or the patient must be released. If a decision is made to seek commitment complete a report to court summarizing (in a paragraph) the patient’s need for commitment. B. Criteria for Involuntary Commitment: In order for a patient to be committed for mental illness, reports of mental illness must be completed by two physicians certifying that in their opinion the patient is mentally ill and as a result of mental illness the patient is (this is the PEC/CEC):

o Dangerous to Others - "Dangerous to others" means the condition of a person whose behavior or significant threats support a reasonable expectation that there is a substantial risk that he will inflict physical harm upon another person in the near future.

o Dangerous to Self - "Dangerous to self" means the condition of a person whose behavior, significant threats or inaction supports a reasonable expectation that there is a substantial risk that he will inflict physical or severe emotional harm upon his own person in the near future.

o Gravely Disabled - "Gravely disabled" means the condition of a person who is unable to provide for his own basic physical needs, such as essential food, clothing, medical care, and shelter, as a result of serious mental illness or substance abuse and is unable to survive safely in freedom or protect himself from serious harm

C. Preparation of a Commitment Evaluation: An appointed faculty (or resident with a full license) will complete an evaluation of the patient for court and determine whether the patient requires continued involuntary inpatient treatment or can be released. There is a document regarding guidelines for resident completion of forensic requirements in the Green Book. Please see Dr. Colon for questions. A sample commitment evaluation: Civil Commitment Guidelines.

1. Read over the petition PEC which was filed, make note of the allegations in the petition and what boxes are checked and what the inpatient recommendations are.

2. Review the chart and hospital course, have in your mind what you would put in the discharge summary. Make sure to note medications the patient has taken or refused and UTOX.


3. Call attending and determine the treatment plan for the patient in regards to court and current status before starting your evaluation.

4. Go to the 10th floor and perform evaluation of patient. The Interview Process A. Inform, patient of non-confidential nature of interview. B. Ask for a brief HPI, eg. “What brought you into the hospital?” “What do you

remember before being brought to the hospital” “How to patient was transported to hospital” and Events leading up to the hospitalization. Can summarize these events no quotes needed.

C. Ask about the allegations of the petition and have those answers in quotes “” D. Specifics standard questions have their answer/reason in quotes “”

Do you believe you have a mental illness? Do you believe that you need medications for your mental illness? Are you taking your medications here at the hospital? Are you going to follow-up outpatient when released? Do you believe that you need court ordered treatment? When you are discharged from the hospital what are your plans?

E. Perform full psychiatric evaluation. With MMSE

5. Call for collateral information if necessary from RPC filer. 6. Before court call attending again and see if discharge plan has been solidified,

make note of medications the patient took before going to court in the chart before the hearing.

7. See patient as a follow-up to note current condition mental state or if any changes from your evaluation

8. Go to court.

Sample Text. Disclosure Statement: I informed the patient that I have been appointed by the court to do a psychiatric evaluation and to assess him for the presence of mental illness and whether he is dangerous to self, others or gravely disabled secondary to his mental illness. He was informed that this evaluation is not confidential and that a report would be presented to court. He was also informed that he has the option of not participating in the interview and if he chooses to do so, his medical record would be used to prepare a report in accordance with the law. He agreed under those conditions. Recommendations: The patient continues to be stabilized on the inpatient psychiatric unit by the inpatient team. The patient continues to refuse medications for treatment of his mental disorder.


His medications will be continued to be offered to the patient. The patient will be provided a safe environment. Side effects from the medication will be monitored. The patient currently does not meet the criteria for being dangerous to self or others. The patient is not endorsing any type of suicidal/homicidal ideation during the evaluation and is not a significant threat to himself or others in the near future. The patient does meet the criteria for being gravely disabled. The patient lacks the insight to realize that he has a serious mental illness which requires treatment. The patient is unable to provide for his basic physical needs evident by not following up for his medical and mental health issues. His psychosis and continued substance usage alters his sense of reality where he believes that he was tortured in the PCU. Thus he is unable to survive safely in freedom or protect himself from serious harm. He will need judicial commitment for continued inpatient stabilization with DHH. Other Recommendations usually on Note to Court, but some recommendation options are as follows: Judicial commitment for continued inpatient stabilization with DHH (Department of Health and Human Services). Judicial commitment for outpatient treatment and follow up with SBHC (Shreveport Behavioral Health Center). Judicial commitment for outpatient treatment with Pines Substance Treatment Center. Can schedule another hearing to decide a change of placement once stabilized inpatient. Judicial commitment to SBHC for outpatient management. Judicial commitment to treatment at Red River Treatment Center with outpatient follow-up with SBHC Judicial commitment to outpatient follow-up with private psychiatrist. Questions court will ask? State your name for the court. Doctor, can you briefly tell me about how and why the patient is in the hospital? Are you the patients treating physician? Do you believe that the patient is suffering from a mental illness? Do you believe that the patient’s condition will improve with treatment? What kind of treatment would you recommend? Do you believe that the patient is DTS? DTO? GAD? Can you tell me the Axis I diagnosis of the patient? What are the recommendations to the court? Is this the least restrictive environment? On cross examination. Was the patient on any drugs on admission? Would this be the cause of the patient’s psychotic symptoms? What medications is the patient currently taking?


Would these medications adversely affect the patient’s ability to stipulate in court? When was the last time you saw the patient? What did you personally observe the patient do? D.Formal Voluntary Admission

o To be offered to a patient if he/she has the capacity to understand the terms of admission and the rules of the inpatient unit, and he/she agrees to abide by said rules.

o Prior to patient signing this form all information must be discussed with the patient.

o The patient must also have the capacity to sign a 72 hour release of formal voluntary admission.

o If at any time during admission the patient loses capacity to sign a 72 hour release of formal voluntary, then at that time the treating physician will initiate involuntary commitment.


Chapter 8 PSYCHOPHARMACOLOGY

A. Neuroleptics (Antipsychotics): These are the drugs that you should be most familiar with. For in the eyes of other doctors, you will be expected to know when to use them, dosages, side effects and contraindications. Neuroleptics can be divided roughly into two groups in relation to their potency. There are High Potency and Low Potency neuroleptics (see Table 1). Potency has been correlated with dopamine receptor binding affinity and thus, ability to cause Extrapyramidal syndromes (EPS) (Table 2). The different neuroleptics are all of approximately equal efficacy. It is the side effect profiles of the two groups which is used to determine your choice of neuroleptic.

In general, the Low Potency neuroleptics are more sedating, have more anticholinergic effects and produce more orthostatic hypotension. Low Potency neuroleptics also lower seizure threshold more than High Potency neuroleptics. Table 1

Neuroleptic Medications

Generic Name Trade Name Relative Potency

Approximate Equivalent Dose

(mg)

Dose Range

Aripiprazole Abilify High-AGO Unknown 5-30 mg Chlorpromazine Thorazine Low 100 Thioridazine Mellaril Low 100 Clozapine Clozaril Low 50 Perphenazine Trilafon Intermediate 10 Loxapine Loxitane Intermediate 15 Molindone Moban Intermediate 10 Trifluoperazine Stelazine High 5 Fluphenazine Prolixin High 2 Haloperidol Haldol High 2 1-20 mg Thiothixene Navane High 4 Risperidone Risperdal High 1 3-6 mg Pimozide Orap High 0.4 Olanzapine Zyprexa Med 10 10-30 mg Ziprasidone Geodon High 120 120-160 mg Quetiapine Seroquel High 300 600-800 mg Need to add new antipsychotics. Under most situations, neuroleptics are undesirable for use as sedatives unless the etiology of the patient’s agitation is clearly psychotic. Benzodiazepines or antihistamines are usually preferable. Psychosis includes delirium for which neuroleptics are highly indicated.

Deleted: Mesoridazine ...

Deleted: Chlorprothixene ...


Table 2 EPS

Syndromes Symptoms Treatment

Acute Dystonic Reaction Abnormal involuntary

movement of various types and oculogyric crises

Cogentin 1-2 mg Or

Benadryl 25-50 mg PO / IM

Akathisia Compulsion to be in motion, restlessness

Reduce neuroleptic and use above meds or propranolol

Parkinsonism Tremor, rigidity and

Akinesia or bradykinesia cogwheel rigidity

Reduce neuroleptic and use above meds

Tardive Dyskinesia Orofacial-lingual

dyskinesia, choreothetosis in limbs and trunk

No consistently effective Tx. Lower neuroleptic

dose. May add Vitamin E. Consider change to atypical

antipsychotic. B. Antidepressants: There are several classes of antidepressants, and even within the same class, drugs may vary considerably in structure, and side effects. When selecting an antidepressant, you will mostly focus on safety and side effect profile. Initiating antidepressant treatment in the ER is not done. The only exception is if the patient can be followed up in one of our outpatient clinics within a week. If this is the case, then the use of a Serotonin-Selective Reuptake Inhibitor (SSRI) is the safest choice. It is almost never justifiable to prescribe a Tricyclic Antidepressant (TCA) or Monoamine Oxidase Inhibitors (MAOI) in these situations. Less than a week’s supply can be a fatal dose. When selecting an antidepressant, the main side effects to consider are: sedation, anticholinergic effects, postural hypotension and impaired cardiac conduction (See Table 3).


Table 3 Antidepressant Profile

Generic Name Trade Name

Sedation

Anticholinergic

Effects

Postural Hypotension

Impaired Cardiac

Conduction

Dose Range (mg/d)

SSRI Fluoxetine Prozac 0/+ 0 0 ± 10-80 Fluvoxamine Luvox 0/+ 0 0 ± 50-300 Paroxetine Paxil CR 0/+ 0 0 ± 12.5-50 Sertraline Zoloft 0/+ 0 0 ± 25-200 Citalopram Celexa 0/+ 0 0 ± 20-60 Escitalopram Lexapro 0/+ 0 0 0 10-20 TCA

Amitriptyline Elavil +++ ++++ ++ +++ Amoxapine Asendin ++ + + ++ Clomipramine Anafranil +++ +++ ++ ++ Desipramine Norpramin + + + ++ Doxepin Sinequan ++ ++ + + Imipramine Tofranil ++ ++ ++ +++ Nortriptyline Pamelor ++ + ± ++ Atypical Bupropion Wellbutrin 0 0 0 0 Trazadone Desyrel ++ ± + PVC’s Venlafaxine Effexor 0 0 0 0 Pristiq Mirtazapine Remeron ++ 0 0 0 MAOI Phenelzine Nardil + 0 ++ 0 Tranylcypromine Parnate 0 0 ++ 0 C. Mood Stabilizers: Lithium (Therapeutic range 0.6 – 1.2 mEq/L)

This is the first line therapy for Bipolar disorder. Before you initiate treatment, get a good history on renal, cardiac and thyroid disease. If patient is female in her reproductive years, ask about her last menstrual period. You should also obtain these labs: CBC, Chem panel, Thyroid function tests, Beta HCG, and ECG. There are different routines the faculty uses to start a patient on lithium. In general, for a healthy adult, a starting dose of 900 mg qd in 3 divided doses is reasonable. Check steady state levels 4 to 5 days after the last increase in dose. Serum level should be checked about 12 hours after last oral dose.

Valproic Acid (Therapeutic range for Bipolar/Schizoaffective D/o: 80-120 ug/mL

Seizure Disorder: 50-100 ug/mL)

Deleted: Nefazodone ...


During therapy with this drug, blood tests to follow: CBC, platelet and liver function should be done. Generally, you can initiate therapy with 20-30 mg/kg/day loading dose for 2 days, then decrease to maintenance dose of 16-20 mg/kg/day.

* Remember that Depakote ER is 80 % bioavailable compared to regular Depakote, adjust dose accordingly. Carbamazepine (Therapeutic range 4-12 ug/mL)

This drug is structurally related to TCA’s and thus may have some of the same side effects. Due to its hematologic and hepatic effects, a baseline RBC, WBC, platelet and liver functions should be obtained before initiating treatment. Start at 200 mg PO BID.

All of these Mood Stabilizers require several days to become effective. Neuroleptics may be used to reduce psychotic agitation initially. The need for continued antipsychotic treatment should be reevaluated at specific times. Newer atypicals may be used as mood stabilizers. If the patient is agitated but not psychotic, Ativan 1 to 2 mg PO or IM is preferable. D. Benzodiazepines: It is strongly discouraged that benzodiazepines be prescribed from the ER. The only real exceptions are if the patient is known to the service and is currently on them. You could give them enough till they can contact their doctor for follow up. The other possible exception: the patient will be seen in one of our out patient clinics within the next few days. Here again only give enough till their clinic visit. Remember any of these dispositions need to be cleared by your on-call faculty. In choosing a benzodiapine, the factors which you may wish to consider are metabolism, and half-life, (see Table). Benzodiazepines metabolized by oxidation will have active metabolites, which will increase their half-life making them long acting. Their half-life can thus be correlated to the liver function history of the patient. The major advantages of long-acting drugs include less frequent dosing, less variation in plasma concentration, and less severe withdrawal. The disadvantages include drug accumulation and increased risk of daytime sedation. Benzodiazepines that are conjugated generally have no active metabolites, and are short acting. Advantages to these drugs are no drug accumulation and less daytime sedation. The disadvantages include more frequent dosing, earlier and more severe withdrawal symptoms.


Benzodiazepines

Generic Name Trade Name Number of

Active Metabolites

Half-Life (hours) Acting

Approximate Dose

Equivalents Alprazolam Xanax 2 12 Short 0.25 Chlordiazepoxide Librium 4 100 Long 10 Clonazepam Klonopin 0 34 Long 0.5 Clorazepate Tranxene 2 100 Long 7.5 Diazepam Valium 2 100 Long 5.0 Lorazepam Ativan 0 15 Short 1.0 Oxazepam Serax 0 8 Short 15 Temazepam Restoril 0 11 Short 5.0 Your major use of benzodiazepines will be to decrease the agitation of patients. In most cases, Ativan 1-2 mg PO or IM is a good choice. For elderly or debilitated patients, you should start at a lower dose like 0.5 mg. The other frequent use of benzodiazepines on-call will be prophylactic use to prevent alcohol withdrawal. The choice of benzodiazepine will vary from person to person. In most cases, you should respond with medication on the parameters of the patient’s B/P, pulse, and confusion. Keep in mind that alcohol and benzodiazepines have an additive effect. Also, withdrawal symptoms will not appear until the alcohol level drops. Thus, benzodiazepines should not be given to intoxicated patients.

Deleted: Flurazepam ...

Deleted: Prazepam ...

Deleted: Triazolam ...


Chapter 9 Inpatient Psychiatry

A.Initial Evaluations 1. All new admits need a History and Physical. Information gathered in the PCU

can be helpful to see how the patient has progressed from initial presentation, however, the H&P cannot be copied from the PCU documentation, and another physical exam should be completed. An H&P format follows, feel free to adjust to personal style.

2. All evaluations should take place in the designated team office, not in patient rooms or the hallway to protect patient privacy.

3. All patients on antipsychotics need a documented AIMS upon initiation of antipsychotics and every 6 months thereafter.

B.History and Physical Format

CC: This is in the patient’s own words such as “I don’t know, the police brought me” HPI: This should begin with identifying information (35yo single, unemployed AAM presented to ER on Request for Protective Custody for threatening behavior, has a documented history of schizophrenia and THC abuse. This is the patient’s 5th admission in the past 2 years). Also identify your informant and their reliability. After the identifying information, proceed with a concise history of the current presenting problems, symptoms and severity placed in chronological order. Symptom onset, duration, timing, context, modifying factors, and associated symptoms are also important. This section gathers information used in medical decision making and diagnosis. Also included in this section are life stressors, changes and/or conflicts, the chronicity or acuity of illness, longitudinal course, and the effect on life functions. Then present a full psychiatric review of symptoms including pertinent negatives. (Patient denies depressed mood and neurovegetative symptoms, no history of manic episodes…) Past Psychiatric History: This includes previous diagnoses, previous medication trials, suicide attempts, hospitalizations, outpatient and substance abuse treatment. Past Medical History: Past Surgical History: Social History:

o Living situation – married? Children? alone? with family? Assisted living? Group home?

Deleted: ¶


o Income - employed? Disability? Medicare/Medicaid benefits? (This is important to know prior to prescribing expensive medication that the patient will not be able to pay for)

o Education - special education vs. regular classes, highest grade completed, if drop out, why?, frequent fights or disciplinary action?

o Abuse – physical, sexual, emotional, neglect o Substance use, frequency and patterns o Legal – arrests, probation, current pending charges, incarcerations o Military o Developmental – birth history and milestones, if known, family

constellation (who were they raised by? Why?) Family History: psychiatric and medical, as well as response to specific psychiatric treatments Medical Review of Systems Current Medications Current Labs Physical Exam: includes the mental status exam and complete neurological exam Assessment: This includes a brief biopsychosocial formulation followed by Axis I-V diagnosis Plan: Should include medications, social work interventions, substance treatment needed, etc… as well as reasoning for all decisions being made

C.Mental Status Exam (the bread and butter of psychiatry):

General Appearance - hygiene, grooming, tattoos, piercings, body habitus, scars, apparent age Behavior – mannerisms, gestures, eye contact Patient-Doctor Interaction – cooperative, hostile, defensive, seductive, evasive Consciousness - Awake, alert, somnolent, sleepy, lethargic, comatose, delirious, orientation (situation, person, place, time) Speech – rate (increased, pressured, slowed), tone (soft, angry), volume, language (vulgar, cursing), articulation, spontaneity Mood – overall emotional state described by the patient (euthymic, dysphoric, euphoric, expansive, irritable, anhedonic, alexithymic) Affect – witnessed emotional state (mood congruent/in-congruent, full, labile, inappropriate, constricted, blunted, flat)


Thought Process – Organized, linear, logical, circumstantial, tangential, perseverative, verbigeration, loose associations, flight of ideas, derailment, clang associations, blocking Thought Content – poverty of content, delusions (bizarre, systematized, mood-congruent, nihilistic, somatic, paranoid, grandiose, erotomanic, persecutory) thought broadcasting/insertion/withdrawal/control, ideas of reference, compulsions, ruminations, preoccupations, phobias, suicidal ideations/plan, homicidal ideation/plan Perceptions – auditory, visual, olfactory, gustatory, and tactile hallucinations, illusions, synesthesia, trailing phenomenon Attention – distractibility, selective inattention, hypervigilance Memory – immediate, recent and remote Insight – Ability to understand true cause of a situation/illness (“What is your main problem?” “Why are you here?” Judgment – ability to assess a situation correctly and to act appropriately within that situation Abstract thinking Intellect Psychomotor activity – echopraxia, catatonia, agitation, hyperactivity, tics, akathesia, retardation of movement, include an assessment of gait

D.Folstein Mini-Mental State Examination A. Orientation

1. “What is the year?” 2. “What is the season?” 3. “What is the date?” 1 point for each correct 4. “What is the day?” 5 points total 5. “What is the month?”

B. “Where are we?” 1. State 2. Country 3. Town 1 point for each correct 4. Hospital 5 points total 5. Floor

C. Registration Name “rose, umbrella, fear” 1 point for each correct Ask patient to repeat all three 3 points total

D. Attention and Calculation Serial 7’s. Stop after 5 responses 1 point for each correct (100, 93, 86, 79, 65) 5 points total E. Recall Ask to recall 3 objects 1 point for each correct 3 points total F. Language

1. Show pencil and watch to patient 1 point for each correct Have Patient name them 2 points total

2. Have patient repeat sentence: 1 point total No if’s, and’s or but’s.

3. Give patient 3 part command: 1 point for each correct Take a paper in your right hand, 3 points total fold it in half, and put it on the


floor. 4. Write, then ask patient to read and 1 point total

Obey: “Close your eyes” 5. Write a sentence 1 point total for noun, verb,

Making sense, spelling and punctuation do not count

6. Copy a design 1 point total for 2-5 sided Figures intersecting to give a 4-sided figure

Averages: Normal Subjects > 27 Uncomplicated Depression ~ 25 Cognitive Impairment 19 Dementia 10

E.Old patients

1. All old patients receive a daily note in the SOAP note format. 2. Treatment team takes place once a week on a designated day for each team.

Patient’s must sign a treatment form stating that their plan of care was discussed, as well as goals and expected date of discharge.


Chapter 11 Resident Resources

1. www.amion.com – this has all schedules, resident and faculty phone numbers, e-mail

addresses and pagers 2. LSU Library website – contains journals, on-line textbooks, and databases for

psychiatry as well as other specialties. 3. Green Book (CD) – handed out during orientation, contains all necessary documents

for supervision, patient logs and more. 4. Process Group – confidential group session held on Fridays where you can get advice

from upper levels on difficult situations, as well as ask any questions that you may have regarding a rotation.

http://www.amion.com/

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