Psychiatric Patients

Posted Oct 2012

View the HMC Policy for Psychiatric Patients

 

Hillcrest Medical Center

2012 Clinical Policy for Psychiatric Patients

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NON-VOLUNTARY Patients:

1.     Non-Voluntary patients (regardless of insurance) will be transported to Tulsa Center for Behavioral Health (TCBH) once they are medically cleared.

a.    TCBH will accept the patient for an evaluation and will decide if the patient needs emergency detention.  If so, they will find a bed for them either in their facility or somewhere in the state. If there are no state funded beds, they will try to find a private/funded bed in Tulsa .  If there is not a bed in the state, then the patient will be transferred back to your facility.

b.    Every Private Behavioral Unit in the state has been determined to be capable of caring for non-voluntary patients.  Please make an effort to transfer to a behavioral unit before admitting to a medical floor. 

2.     A Third Party Statement must be completed on each patient.

a.    The Third Party Statement may be filled out by anyone who is concerned about the patients’ safety or who witnessed concerning behavior (i.e. family, COPES, social worker, nurse, physician).

b.    If the patient already has a third party statement by someone else, you do not have to fill out another. UNLESS you have witnessed behavior that is different or more extreme than is already documented.

c.    The Third Party Statement MUST have enough detailed information to justify the placement of the patient into police custody (it cannot simply say “suicidal”).

d.    The police can refuse to take custody and transport a patient if they feel there is not enough evidence written on the Third Party Statement to justify this action.

e.    The psychiatric team at TCBH will do an assessment and they will decide if the patient needs an Emergency Detention (ED).  The term EOD (Emergency Order of Detention) is no longer used for the legal document and is outdated terminology.

3.     Establish Medically Clearance. The Emergency Physician evaluating the patient will determine what (if any) tests need to me performed to establish that the patient is medically stable for psychiatric admission.

a.    The patient must be stable enough to be discharged into non-medical (police) custody, transported to TCBH and wait (up to 2-3 hours) for their psychiatric evaluation.

b.    Although not necessary for medical clearance, we have agreed that we will make a reasonable attempt to get a urine drug screen as it will eventually help guide the patient’s treatment.

c.    Don’t delay discharge for urine drug screen results, as these can be faxed to TCBH when you get the results back.

d.     The ETOH level does not determine medical clearance.

HOWEVER-

                                                         i.  The patient needs to be observed long enough to show that they are sobering OR a repeat level showing that the ETOH is trending downward.

                                                         ii.  The patient must be sober enough to sit and hold a conversation during their intake evaluation.

                                                         iii.  The patient needs to be at low risk for going into with-drawl or having a seizure while waiting with the police in the waiting area for their evaluation.

4.     Once you have verified that the receiving facility (TCBH/Private Behavioral unit) has the capacity to care for the patient:

a.    Notify them that the patient has been medically cleared and will be coming to their facility for an evaluation.

b.   You are transferring a stable patient from our facility into non-medical (police) custody. Even though this technically does not fall under EMTALA, please fill out transfer paperwork for consistency.

c.    TCBH/Private behavioral units cannot demand that the ETOH level be below a certain number, HOWEVER, they can send the patient back to the Emergency Department if they do not feel they are medically stable for an evaluation.

5.     The Tulsa Police Department (TPD) will come to the Emergency Department and take the patient into protective custody (handcuffs-discretionary), transport the patient to TCBH/Private Behavioral Unit and be responsible for them until care is turned over to the staff at TCBH.

a.    If the patient  has been accepted by a Private Behavioral Unit, TPD should be able to transport them.  This is new information for the officers as TPD historically would only transport to TCBH.  Please call dispatch and speak with a TPD supervisor if the officer is unfamiliar with this option.

b.    TPD has the right to refuse to take a patient into custody if they are not comfortable with the patients medical stability or if they do not feel there is enough written justification on the Third Party Statement. Also, Officers may refuse a patient if what is written still doesn’t meet State Law requirements.

c.    Patients brought by TPD to TCBH are put at this top of the list to be assessed, however the wait with police in the waiting area may be up to 2 hours.

d.    To be consistent, fill out the transfer paperwork and check that the patient has an EMC (Emergency Medical Condition) , which has been stabilized.

e.    Please send a copy of the patients Emergency Department Record and a copy of any tests done in the ED. 

f.     Do not wait on results of the Urine Drug Screen to disposition the patient. However, please have them faxed to TCBH when you get them back.

 

VOLUNTARY Patients

Any patient who has an Emergent Psychiatric Condition but who is willing to get treatment may be determined Voluntary.  However, if you have any concerns about the sincerity of their intention to stay or if you feel they need physical detention, then a third party statement needs to be filled out and the patient sent to TCBH.

Patients NOT appropriate for Voluntary Psychiatric Admission:

1.      History of violence or currently exhibiting violent behavior

2.      Known history of committing rape, molestation or serious crime

3.      Requiring physical restraints

4.      Any concern for the safety of Hospital personnel or EMSA who will be transporting the patient.

Once you have determined that you have a VOLUNTARY PSYCHIATRIC ADMISSION:

1.     Establish Medically Clearance. The Emergency Physician evaluating the patient will determine what (if any) tests need to me performed to establish that the patient is medically clear.

a.    The patient must be stable enough to be transported either upstairs by our nurses or by EMSA/family to another facility.

b.    Although not necessary for medical clearance, we have agreed that we will make a reasonable attempt to get a urine drug screen as it will eventually help guide the patient’s treatment.

c.    Don’t delay disposition for urine drug screen results, as these can be faxed when you get the results back.

d.    The ETOH level does not determine medical clearance.

HOWEVER-

                                                         i.  The patient needs to be observed long enough to show that they are sobering or a repeat level showing that the ETOH is trending downward.

                                                         ii.  The patient must be sober enough to sit and hold a conversation during their intake evaluation.

                                                         iii.  The patient needs to be at low risk for going into with-drawl or having a seizure during transport or during their evaluation.

e.    Patients must be able to perform activities of daily living, and be physically able to function in the unit. 

f.     Some patients may be found to have medical conditions that would preclude them from functioning in the behavioral unit and should be Admitted to a Medical Service with Psychiatry Consult.

Examples include:

                                                         i.  Active, incapacitating physical illness

                                                         ii.  Bed Bound

                                                         iii.  Requiring IV catheter

                                                         iv.  Frequent vital signs (<4hrs)

                                                         v.  Severe or profound mental retardation

                                                         vi.  Overdose with long acting medications

g.     Hillcrest Behavioral unit CAN take patients in wheelchairs and who require oxygen.

FIRST call Hillcrest Behavioral Unit (x7180).  If they have a bed available they will accept the patient, regardless of their ability to pay. However, if they are self pay, please try to transfer to TCBH as they want the unfunded patients.

a.    Every patient that is accepted upstairs WILL BE ADMITTED and seen by a psychiatrist in the morning.

b.   They can only do one admission at a time (~40 minutes) so your patient will stay in the Emergency Department until they can admit them into the locked unit.

c.    It is our responsibility to keep the patients safe until they are admitted upstairs.

d.    Be aware that the nurses will be giving your patient an information sheet to ensure they understand it is a locked unit and they won’t be allowed to smoke (but given nicotine patches). If your patient changes their mind about being voluntarily admitted to the unit then fill out a third party statement and send them to TCBH.

3.     If the Hillcrest Behavioral Unit is full, then the patient must be transported to another mental health facility.

a.    If the patient is self pay, Call TCBH first.

b.    There are many other facilities in town that MUST take your patient REGUARDLESS OF INSURANCE STATUS if they are not full.

c.    Since your patient has an Emergency Medical (Psychiatric) Condition and needs a service that we are unable to provide (unit is full), other facilities that have the capability must take the patient regardless of the patient’s ability to pay.

d.    Other Inpatient Psychiatric Units that take Voluntary patients in Tulsa include:

                                                         i.  Parkside (918)-588-8888

                                                         ii.  Laureate (918)-481-4000

                                                         iii.  Brookhaven (918)-438-4257

                                                         iv.  TCBH (918) 293-2100

4.     Once accepted to another facility you must ARRANGE TRANSPORTATION of the patient and understand that you are responsible for the safety of that patient until they reach the receiving hospital.

a.    EMSA is the safest method of transporting a voluntary patient from one hospital to another.

b.    You can let a family member transport the patient.  However, you are liable if you knew the patient was suicidal and they harmed themselves before they were EVALUATED at the accepting facility.

                                                           i.  Understand that your voluntary patient may wait hours in the waiting room of the receiving facility before an evaluation.

 

Additional Resources

            COPES  (Community Outreach Psychiatric Emergency Services)

(918)-744-4800

1.    State funded crisis unit that can come to the Emergency Department to help evaluate your patient to determine if an Emergency Medical/Psychiatric Condition exists (should be very rare occasion).

2.    Please call them for anyone who you are discharging (because they didn’t meet criteria for involuntary detention) but who you feel needs close psychiatric follow up.

3.    Will call or go to the patient’s home within 12-24 hours to check on the patient and arrange mental health follow up appointments at Family and Children’s Services.

 

CHILDREN Ages 4-17

Hillcrest Child and Adolescent Services (located at OSU Medical Center)

1.    24-hour Intake Department 918-599-5880.

2.    90 Bed inpatient unit with Acute and Residential (sub-acute) services to children and adolescents

             Parkside Hospital

1.      24-hour Intake Department 918-588-8888

2.      15 bed inpatient unit with Acute and Residential services for (ages 10- 17 only).

             Shadow Mountain Behavioral Health System

1.      24-hour Intake Department 918-492-8200.

2.      108 bed facility with Acute and Residential services to children and adolescents 

1.       Medically clear the child as you would for an adult.

2.       Notify the Facility that you have medically cleared the child and are sending them for an evaluation.

3.       Fill out transfer paperwork

4.       Arrange transportation by the safest means possible.

a.     You must determine if it is safe for the child to be transported by the parents.

b.    If your patient is violent or not safe in their legal guardian’s care then fill out a third party statement and call TPD for transportation.

c.    COPES team can also be called to the ED to help transport your pediatric patient to the pediatric psychiatric hospital safely.