Psychiatry

We are fortunate to have Psychiatry located in the ED, taking care of psychiatric patients which are typically housed in the Yellow Zone. Our psychiatric residents are from the Harvard Longwood Psychiatric Residency Program.

Pre-Admission Medical Clearance

Prior to discharge from the ED before admission to an inpatient psychiatric unit, every patient should have a medical assessment by a physician documenting “medical clearance.” Medical clearance determination in the emergency setting indicates that the patient is physically stable and can be transferred to an inpatient psychiatric service without foreseeable deterioration of his/her medical status.

Baseline medical clearance for all psychiatric admissions should include:

    • Full set of vital signs (including O2 sat)
    • Medical History and ROS
    • Physical Examination
    • Serum and Urine Toxic screens if indicated
    • Pregnancy testing in women of reproductive age

Generally, we order CBC, Chem7, serum and urine tox, urine hcg, recognizing that some of these may not be medically indicated but are generally requested by admitting psychiatric facilities.

Decisions to defer medical clearance should be based on appropriate medical decision-making and documented in the patient’s record.

Ancillary Testing

For patients deemed to be at Low Medical Risk in accordance with the following guidelines, additional laboratory testing may not be indicated prior to admission.

Low Medical Risk:

    • Age between 15-55
    • No acute medical complaints.
    • No known significant medical conditions (e.g. DM, Renal Failure) or new psychiatric or physical symptoms.
    • No evidence of a pattern of substance (drug or alcohol) abuse.
    • Normal vital signs, normal gait, and fluency of speech.
    • Normal assessment of memory and concentration.

Exceptions would include baseline labs in anticipation of medication initiation during hospitalization, serum levels for prescribed psychiatric or medical medications, etc.

Patients who do not meet criteria for low medical risk are not automatically considered to be at high medical risk.

Potential for High Medical Risk:

    • Any elderly patient (>65 years old) with acute psychiatric presentation.
    • Any patient with suspected toxic ingestion. This includes patients intoxicated on alcohol who are not ambulatory or cannot produce intelligible speech.
    • Any patient with a suspected substance withdrawal syndrome.
    • Any patient unknown to BIDMC (or known patients without documented psychiatric history) with acute mental status change.
    • Any patient with known psychiatric history but an atypical and acute presentation.
    • Any patient with suspected delirium of any cause.
    • Any patient presenting with acute physical complaints or known medical condition of uncertain status.

Medical work up for patients meeting any of the above criteria should be dictated by clinical judgment.

Any significant concerns on the part of the receiving psychiatric service regarding the medical stability of a patient for admission should be reviewed directly by the accepting physician and the physician conducting medical clearance.

Evaluation

After you evaluate a psychiatric patient and deemed them medically cleared by history, exam, and workup, you should consult psychiatry. Psychiatry can be consulted before labs have resulted if you are certain from just history and exam that the patient is medically cleared.

It has been general practice here that we do consult psychiatry right away for intoxicated patients with a history of inpatient psychiatric admissions who endorse suicidal ideation while still intoxicated, with the expectation that the ED team will re-notify psychiatry when the patient becomes clinically sober for an interview. However, if you suspect that the patient will fully recant their SI when they are sober, it is okay to defer a psychiatric consultation until the morning Observation attending re-evaluates the patient.

If you suspect from your initial history that the patient will need inpatient admission, you can admit them into ED Observation. Otherwise, if there is a chance that the patient will be cleared to return home, you can keep them active.

Admission

Psychiatry will page the primary provider when a psych patient has a bed available.

BIDMC has a inpatient psych floor called Deaconess 4. If the patient is being admitted to Deac 4, you do not have to do anything else in the admission process including no holding orders needed. The patient will automatically go upstairs and disappear off of the dashboard.

If the patient is going to an external facility, you will need to release the patient from observation and discharge the patient. The ED RN will arrange for transportation. While ideally you should finish your note prior to discharge, it is not required as most psychiatric facilities will refer to the psychiatric consultation note instead.

See attached seclusion protocol.