How to Make Medical Clearance Decisions Without Erecting Unnecessary Barriers to Admission Barry Ginsberg, MD Medical Director BayRidge Hospital Chief, Department of Psychiatry Northeast Hospital Corporation What Are Unnecessary Barriers?  Attempts to assess a patient’s medical status in ways that are not likely to yield improved acceptance decisions – From E.D’s:  Overreliance on labs; making acceptance decision contingent on specific result  Communication via non-medical personnel  Taking psychiatrist’s medical assessment (without examining the patient) over E.D. physician (who has examined the patient) How Can You Tell if You Should Take This Patient from an E.D.? 1. 2. Find out what medical care the patient is expected to need (from the E.D. physician) What are the medical capabilities of your facility and can it meet that need? BayRidge Hospital Medical Capability   General: Patients must be physically and mentally able to participate in their care. The facility is fully handicap accessible. 1. Responsibility for Medical Care:   2. Medical Consultation:   Phlebotomy services are available on a routine basis Monday-Friday. Phlebotomy services are available on an emergency basis on weekends and holidays. 4. Radiology:   An internist is available to do general medical consultations and follow-ups Monday-Friday only (holidays as well as weekends are excluded). No medical or surgical specialty consultations are available. 3. Laboratory:   An attending psychiatrist is responsible for the medical care of each inpatient. A psychiatrist is present in the hospital at all times. No radiological services are available at BayRidge Hospital. Providing necessary transportation and accompanying staff to Beverly Hospital can be problematic. 5. Nursing Services:  Uncomplicated wound care and ostomy care can be managed, but BayRidge does not have the capacity to do intravenous therapy. Other nursing needs should be reviewed on an individual basis. How Can You Tell if You Should Take This Patient? DO:     TALK TO THE EMERGENCY DEPARTMENT M.D. PROVIDE MEDICAL CAPABILITY INFO TRY TO MAKE A CONSENSUS DECISION THE EMERGENCY DEPARTMENT M.D. IS IN A BETTER POSITION TO MAKE A MEDICAL JUDGEMENT DON’T:    TRY TO DIVINE THE MEDICAL STATUS THROUGH LABS COMMUNICATE THROUGH NONMEDICAL PERSONNEL MAKE A UNILATERAL DECISION If You Do Accept a Patient Who is Medically Unstable: Reality-based:  Could deteriorate medically at psychiatric facility  Could need tests unavailable at facility  May need to be transferred to medical facility Not so reality based:  Our psychiatrists and nurses will have to take care of this patient  We may not be familiar with/feel comfortable with medical issues  We could be responsible for bad outcome! Direct Admission Without Medical Clearance Which patients can be admitted without going through a hospital emergency department? Community Medical Clearance Standards Workgroup  Widespread agreement that not all patients need an ED medical clearance evaluation – MGH “low medical risk” group Widespread agreement about extra cost (to insurers), delay (to patients), and volume (to ED’s) caused by universal medical clearance  So which patients don’t need medical clearance?  Medical Clearance Task Force Consensus Statement (2001)  Low medical risk patient – 15 < Age <55 – No new medical complaints – Psychiatric symptoms are consistent with prior diagnosis – Physical exam is normal  Laboratory studies not indicated on low medical risk patients Medical Clearance Task Force Consensus Statement (2001)  There is no clear definition to “medical clearance” but within reasonable certainty: – No medical cause for psychiatric complaints necessitating medical intervention – Patient is medically stable enough for transfer to the intended destination  “Does not indicate absence of ongoing medical issues…(nor) guarantee that there are no undiagnosed medical conditions” Community Medical Clearance Standards Workgroup  Insurmountable problems implementing even the most basic medical assessment (e.g. vital signs)  Difficult to construct a “cookbook” of guidelines  Clinicians are not trained to identify mental status and behavioral changes with organic etiology (e.g. delirium) In the Absence of Standards for the Medical Assessment of Patients in the Community, How Do You Decide Which Patients You Can Accept Directly and Which Should be Sent to an E.D. for Medical Clearance?  Assume that the information you have received may be inaccurate and/or incomplete—based on what the non-medical clinician sees and what patient says.  When in doubt, send the patient out to an E.D., especially after assessment at your facility.  An extra leg of transportation for some (crisis team to psychiatric facility to emergency department) is preferable to emergency department medical assessment for all Freestanding psychiatric hospital vs. general hospital psych unit    Freestanding (BayRidge) Physician (usually psychiatrist) always available, can assess pt on arrival Limited medical capability    General hospital unit (Beverly) Psychiatrist often not on unit, physicians are in building but often not available Less robust medical assessment on admission, in the midst of extensive medical capability Where is the Call Coming From?  If you do send the patient to an E.D. for medical clearance after arrival, local E.D. may object if patient lives far away  If you have been “burned” by previous referrals from a team or clinician  Get to know frequent community referrers, increased confidence On the Phone with Screening Team Do we know the patient?  Does the patient report physical symptoms, wounds, infectious diseases?  What ongoing medical problems does the patient have, and what services or equipment do they require?  If yes, review with receiving psychiatrist  What substances does the patient use? Intoxicated? Alertness?  Which Patients Need Medical Clearance?  Overdoses, known or suspected  Medical illnesses: hard to take a “cook book” approach  Presence of medical symptoms beyond the facility’s capacity to evaluate and manage (e.g. chest pain, but not diabetes unless ill) Medical Clearance Guidelines  SITUATION SPECIFIC REQUIREMENTS  S/P Overdose – – – – –  Intoxicated Drug User –  CBC (requested) not required Chem panel (requested) HCG (pregnancy test) for potentially fertile females (requested) not required Concomitant Medical Illness –  EKG (requested) not required Friday and Saturday – – –  Patient is alert, observed >2 hours (without deteriorating level of consciousness) Elderly (>70 years old) –  Patient is alert, observed >2 hours (without deteriorating level of consciousness) Opiates –  EKG (requested) not required Alcohol –  Medical Clearance by Emergency Department requested but not required Cocaine & Amphetamines Dependence/Abuse –  Medically cleared by Emergency Department, BayRidge MD must talk to ED MD to get handoff Toxic Screen drawn (DAU-7 or equivalent preferred) >3 hours observation without deteriorating level of consciousness EKG (requested) If the patient has had a positive response to Narcan (naloxone) in the Emergency Department, transfer to BayRidge should be delayed until it has been determined that the patient is alert after Narcan has been cleared. Patients who have ingested long-acting opiates may deteriorate if they do not receive repeated Narcan dosing, which should not be done at BayRidge Patient requires no greater medical capability than that found at a residential level of care (e.g. staff administers medications, can assist patient with own oxygen supply) Patients Requiring Immediate Medication (i.e., Behaviorally Out of Control) – HCG (pregnancy test) for potentially fertile females (if possible) Substance Use/Intoxication Crucial issue is whether the patient’s level of alertness is deteriorating--should be observed for at least 2 hours without deterioration  Toxic screen upon admission?  Special attention to patients who have received Narcan—may deteriorate when it wears off and need repeated doses  Blood alcohol level is not useful to determine readiness for transfer  Psychosis  May need to be sent for medical clearance after being assessed by psychiatrist at the psychiatric facility if there are indications of delirium If Medical Capability is Reduced on Weekends, More Likely to Request Medical Clearance  E.g. internal medicine consultation may not be available at freestanding hospital BayRidge/Beverly experience May-August 2010  111 referrals for admission from the community/ 1176 total admissions  9.4% of admissions were community referrals  Trend over these 4 months  23% of community referrals sent for medical clearance # Community referrals May-August 2011 40 35 Number of Committments 30 25 20 15 10 5 0 May June July August BayRidge/Beverly experience May-August 2010  3.0% of medically cleared admissions transferred to medicine during admission  3.1% direct (i.e. without medical clearance) admissions transferred to medicine during admission Conclusions  In the absence of standards for direct referrals without medical clearance, appropriate screening upon arrival at the psychiatric facility is important  Make facility-specific medical capabilities explicit, and where possible specify conditions that require medical clearance Conclusions  Have an efficient process for determination of medical clearance decisions in the (frequent) situation where medical judgment is needed  So far, so good