Medical Clearance for Psychiatric Unit

[smcRN2592, ADN]

Topic: Medical Clearance

In your experience, what have you seen that constitutes “med clearance” for a psych unit?

Particularly, at a free-standing psychiatric facility. Geriatric patients. I’m trying to brainstorm to present some type of policy that constitutes med clearance and can give our staff some back-up in the future if an appropriate admit presents itself.

Backstory: I work on a geriatric psych unit that could once handle some level of patients being medically “unstable” due to the unit being part of a medical hospital. Last year, all of the inpatient medical units closed. More recently, the emergency room closed. We are now the only unit in a building that is essentially empty aside from some outpatient offices. We now have to call 911 if a patient is appearing to be medically unstable or suffers an unwitnessed fall/fall with head strike (which can be common given the population). It is understandable for this population to not but 100% healthy (obviously) but we have an extensive history of having to transfer patients to a higher level of care within 24 hours of admission, even when our ER was open. I think this could be avoided with policy that requires medical intervention for abnormalities before transfer.

Example: Report from a medical hospital’s psych holding in their ER for a new admission. The intake paperwork said the BP was 157/101. In report, I got that the BP was now 167/122 and they had not given any BP meds or other intervention since the patient arrived (day before). They did give patient tylenol for a headache. Patient has a history of stroke/TIA, 60s year old M, full code, schizophrenia dx. Would this be acceptable in your experience? Or would you require some type of intervention first?

[canoehead, BSN, RN]

The example you give, 157/101 wouldn't make me turn a hair for any patient entering an emergency room. The stress of the ER easily will give you that BP. The second BP, I would retake manually if I was the ER nurse, and I'd mention to the doc to make sure the patient was ok to send. Our docs do screening bloodwork, and I know that with normal kidney functions, they'd still send the patient and attribute the BP to stress.

Higher BPs than that, it's not recommended to treat immediately with meds to lower them, unless there's evidence of end organ damage. Spots in front of eyes, headache, higher creatinine/BUN The body can become used to higher pressures and if we try to bring someone down to normal quickly they get nauseated, and dizzy. If they are treated in the ER we bring them down twenty points at MOST, and then monitor. The second BP you mentioned, if they did not have psych problems, our docs would not treat in the ER, they would refer to PCP and ask the patient to get a few BPs written down at the drug store before they went to their appointment (to rule out white coat syndrome).

Sending a patient to psych, and in anticipation that they might get new meds or sedating meds, it's safer to let that one BP ride. Hypotension is more dangerous than hypertension.

With your patient's history, I would say in report that I notified the MD of the second BP and if he had any further instructions. I wouldn't delay transfer unless they had stroke symptoms.

[DAL2010]

I disagree with canoehead. I have a strong background in Cardiac/Neuro ICU/IMC and have worked the past number of years in a free-standing Psych hospital, in Admissions. A big part of my job is screening patients for medical clearance (in addition to Psych need and appropriateness). We will not accept a pt with systolic above 159. We also have parameters for EKG, HR, Electrolytes, BAL, WBC, Platelets, BG, CIWA, CINA, 3rd trimester pregnancy, Med levels (eg Lithium, Depakote) and Acetaminophen. We also require all patients to be fully ambulatory on their own and able to toilet & feed themselves.

Canoehead seems to speak from an ER perspective, and sometimes when I'm screening, I get pushback when I instruct ER staff to replace K of 3.2 or give insulin for elevated BG, to facilitate patient transfer to my facility. It's all in the interest of patient safety - as a psych hospital, we are not equipped with the supplies to handle a CVA or MI or to stop bleeds (no IV supplies or IV meds in the building). I advocate for patients to be in the safest environment for them: they can receive Psych or TelePsych in the ER or medical hospital, but they don't really receive emergency or life-saving medical treatment here. If that means transfer to my facility is delayed, so be it.

[MunoRN, RN]

12 hours ago, DAL2010 said:

I disagree with canoehead. I have a strong background in Cardiac/Neuro ICU/IMC and have worked the past number of years in a free-standing Psych hospital, in Admissions. A big part of my job is screening patients for medical clearance (in addition to Psych need and appropriateness). We will not accept a pt with systolic above 159. We also have parameters for EKG, HR, Electrolytes, BAL, WBC, Platelets, BG, CIWA, CINA, 3rd trimester pregnancy, Med levels (eg Lithium, Depakote) and Acetaminophen. We also require all patients to be fully ambulatory on their own and able to toilet & feed themselves.

Canoehead seems to speak from an ER perspective, and sometimes when I'm screening, I get pushback when I instruct ER staff to replace K of 3.2 or give insulin for elevated BG, to facilitate patient transfer to my facility. It's all in the interest of patient safety - as a psych hospital, we are not equipped with the supplies to handle a CVA or MI or to stop bleeds (no IV supplies or IV meds in the building). I advocate for patients to be in the safest environment for them: they can receive Psych or TelePsych in the ER or medical hospital, but they don't really receive emergency or life-saving medical treatment here. If that means transfer to my facility is delayed, so be it.

This is a persistent source of frustration for hospital staff, and for good reason.

To use your SBP of 160 cutoff for admission, there are established practice guidelines for treating hypertension in hospitalized patients, and aside from specific medical dx and conditions (acute hemorrhagic CVA, decompensated HF, etc), treating an SBP of 160 in the general hospitalized patient population is not good practice. Practice guidelines indicate treat of hypertension in hypertensive emergency (SBP>180, DBP >120, and end organ failure), but treating SBP of 165 is likely to do more harm than good, particularly when it's due to underlying cause, such as an acute psychiatric presentation, in which case the appropriate practice is to treat the underlying cause.

So inpatient psych won't take a patient with persistent medical issues because they aren't capable of managing those issues, but they will dictate to the treating physician how they should medically treat they patient they themselves refuse to medically treat. I'm sorry, but that's BS.

Another frustration is that an acute psychiatric presentation is itself worthy of treatment, often as a higher priority than relatively minor and non-acute medical issues.

Lets say a patient is admitted to the hospital under a hospitalist for elevated BP, which then turns out to be because the patient is having an MI and is actively infracting, the hospitalist then seeks Tx by a cardiologist, would it be appropriate for the cardiologist to say they won't get involved in the patient's care until the hospitalist better manages the BP (which is due to the infarct the cardiologist won't deal with)? That of course would be grossly negligent care, so I don't see why it should be considered acceptable for psych.

[canoehead, BSN, RN]

I argue that if we would discharge them home with that BP, they are safe to send to psychiatry.