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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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

Dont 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 doctors 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 patients in the PCU currently. You will see their Bed numbers, name, age, complaint, triages 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 patients 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 patients 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 patients chart by double clicking on the patients 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 patients facesheet. This can be done from the Trackboard, but also from the patients 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, Ive got a patient for you After you review the patients 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, Ive 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 persons 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 patients 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 patients 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 patients 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 patients 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 patients 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 clinics 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 patients 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 patients 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 patients 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 Patients 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 patients 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, dont order the medications for the patient. Choose Dont 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

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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.

2. Inpatient Consults

***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 PECd 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 physicians 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

Page 2 of 5 Guide to the Rural Community Psychiatry Rotation, HPLMC

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

Page 3 of 5 Guide to the Rural Community Psychiatry Rotation, HPLMC

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 Doctors 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 italways use this access door. The nurses will show you the Work Hours Log sheet and show you around the unit.

7.) Call the administrators 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.

Page 4 of 5 Guide to the Rural Community Psychiatry Rotation, HPLMC

DAILY ROUNDS

1.) Arrive at 08:00 at prepare for the days 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 Physicians 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.

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

LODGING

1.) Make reservations at the Alexander Fulton Hotel in advance of your rotation. There is a physicians 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.) Critics 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 youve 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 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

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

Psychiatry On-Call LSUHSC

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.

2. Inpatient Consults

***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 PECd 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,

Psychiatry On-Call LSUHSC

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 physicians 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

Psychiatry On-Call LSUHSC

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. PECs 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 Dont 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.

7 Rev December 2011

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-Is and IIs discuss all situations with the faculty back-up. The PGY-IIIs and IVs 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.

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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.

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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 patients 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 PECd 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 patients safety is on that doctors head, not yours. Most services do not normally discharge patients at night.

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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 patients name 3) Obtain the number from which the patient is calling

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4) Learn both the patients 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 youre 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 patients 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 doctors explanation and assess their understanding of their condition.

Points to consider in formulating an opinion about a patients 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 patients suicidal and ho