Harbor:PED psych patients

Is the patient seen in PED or Psych ED?

• Age
  • Patients age 15 years or less should be seen in PED, with psychiatry consulted
    • If a patient is particularly aggressive or an elopement risk, they may be transferred to Psych ED after consultation with Psychiatry
  • Patients age 16 years and above can receive a screening MSE in triage and then be sent to Psych ED in some cases
    • Patient should have no medical issues that require PED evaluation
    • If on a 5585 or 5150 hold, EMS or police willing to wait with patient outside the Psych ED until patient can be brought back
    • If brought in voluntary with family, PED physician ascertains that patient is safe to wait outside Psych ED with family and unlikely to leave without being seen
      • Patients and family may also be referred directly to Exodus if appropriate (see below)
    • For anyone at high risk of an acute mental health issue, it is best to keep them in the PED unless the Psych ED is able to take them directly back
      • Discuss with Psych ED physician to physician
  • Patients age < 18 years cannot be roomed with patients aged 18 and older in the Psych ED, so the Psych ED may not be able to accommodate them immediately
• Chief complaint and past mental health history
  • Some patients meeting age criteria to go to the psych ED, but being seen for newer onset eg depression or suicidality may not be good candidates for being seen in the Psych ED
  • Conversely, some younger patients normally kept in PED may have previous history of severe aggression or elopement requiring them to be seen in Psych ED

PED practitioner evaluation and orders

• Perform a medical screening exam to ensure there are no non-psychiatric complaints or disorders that need medical attention
• If the patient is on a 5585 (< 18 years) or 5150 involuntary hold, order the hold in Cerner
  • Enter the date and time the hold was placed (found on the hold paper)
  • Enter the reason for the hold (danger to self, danger to others, gravely disabled)
  • Choose "continue" as we are not instigating the hold, merely continuing it
• Order regular diet, vital signs q shift, 1:1 observation, Consult to ED Psych (this puts a P on the track and puts the patient visible on Psych ED track)
  • Consider ordering a urine pregnancy test and urine toxicology screen as indicated

Psychiatry consultation

• Monday through Friday, non-holidays, daytime hours, the Child Psych fellow will consult
  • Call schedule is either posted on the bulletin board or available on MedHub
• Other times, the Psych ED resident will consult
• Department of Psychiatry has committed to providing initial consultation within 4 hours of patient arrival
• After initial evaluation, sometimes patients will be held in the PED for a period of time to gain additional collateral information from caretakers
  • If a patient arrives in the evening or night, this period of time may last until the next morning
  • Patients should not be in the PED > 12 hours without a disposition
• Disposition will be either safe for discharge with outpatient follow-up or bed search for admission to a psychiatric facility
  • Psychiatry consultant should put in an order for Bed Search, and a B should be visible on the track
  • If discharging, Psychiatry consultant should discontinue any 5585 or 5150 hold

Ongoing care of patients in PED

• Sometimes patients are in the PED for a prolonged period of time awaiting transfer to a psychiatric facility
• The PED team is caring for the patients, with Psychiatry as consultants
• Psychiatry should put in their consult note any medications that need to be continued or initiated, including the dose
  • The PED team will place the actual orders for the medications in Cerner
• Psychiatry should also put in their consult note preferred prn medications in the case of patient agitation
• PED physicians should order outside time for patients, and make sure they are having access to a shower at least every other day

Exodus

• Patients are eligible for evaluation at Exodus if:
  • Age 12 years or older
  • Not in juvenile justice or law enforcement custody
  • Do not have severe autism or mental retardation
  • Have Medi-Cal insurance or no insurance (cannot have private insurance)
• They may be already on a 5585 or 5150 hold, or may be voluntary
• Exodus intake number 800-829-3923
• Transport to Exodus if accepted
  • If on a hold, call 562-295-4617 for county transport
  • If voluntary, can send with parent if safe
    • Else, can consult Harbor Psychiatry to place a hold for transport by county transport

See Also

• Harbor:Pediatric ED (main)

Authors

Kelly Young, Ross Donaldson